DOCTORAL DISSERTATION (PhD) THESIS STATEMENTS

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1 DOCTORAL DISSERTATION (PhD) THESIS STATEMENTS Developing Nurse Training in the Field of Community Nursing Zoltán Balogh Subprogram and subject supervisor: Dr Judit Mészáros Head of Institute, Dean, College Professor Semmelweis University Faculty of Health Sciences Nursing and Health Pedagogy Institute Semmelweis University Doctoral School Pathological Sciences School Budapest, 2008.

2 Contents Introduction 3 Summary of research procedure 5 1st phase of research: development of professional and moral recognition of graduate nurses 6 Application of the findings of research 1 as a teaching strategy 8 2nd phase of research: investigation of the professional development of specialists working in the field of home nursing care 10 Application of the findings of research 2 as a teaching strategy 14 Announcements relating to the thesis topic

3 Introduction The system of student nurse training has undergone many significant changes in the last decade. When the nearly sixty year history of the training system is being investigated, four major development periods can be distinguished. The first period is represented by the late forties and the early fifties when nursing training after the Second World War was established. After a temporary stagnation, special training schools and specialisation courses gave a fresh impetus to further development. This process was aided by the establishment of the college of health care in1975, which was the time when the healthcare specialist trainer and head of institute programmes started. The third period of the development of nurse training, i.e. the nineties, is marked by the appearance of the law on vocational/specialist training and the National Qualifications Register (hence: NQR). This period brought a change in quality in the history of nursing training in this country since even in terms of European standards remarkable forms of training started, (such as nurse training, graduate/registered nurse training based on the school-leaving certificate) that are accepted in many different countries of the world. Way ahead of its time since the early and mid-nineties nursing education in this country has been applying training systems developed according to European norms and expectations. The fourth phase of development, in accordance with our European Union membership, is characterised by the adaptation of the measures of the Bologna process, i.e. the establishment of the two-cycle higher education system, changes in the professional groups of the National Training System and the establishment of competence-based, credit-assessed modular training programmes. Since the establishment of college level nursing training, graduate nurses and those who have graduated have steadily been struggling to reach their professional status within the hierarchy of healthcare occupations. The intensity of nurses aiming their professional status to be recognised varies considerably in various social and historical ages. Nearly two thirds of health care professionals are nurses who make a significant contribution to the recovery of individuals, families or the prevention of diseases. Nevertheless, their occupation does not seem to be recognised among the profession themselves, nor in the whole of society. As health care is improving, nurses professional knowledge is constantly being enlarged along with its increasingly demanding requirements. At the same time the profession of nurse is at present in the state of submission even at the beginning of the 21 st century. Nurses status, their place in the division of labour, their role and rank does not change considerably even - 3 -

4 after graduating from college. This investigation aims to explore exactly these facts, find the underlying causal links and explore further possibilities for the institution. As a consequence of the crisis in the economy, the crisis in health care has become more and more apparent. Deteriorating economic conditions, the price explosion in health care have also aggravated the situation. This phenomenon is of a structural character similarly to other spheres of the economy so that a solution can only be a basic structural change in the institutions in an improving economic situation, as well as their adjustment to real needs. Owing to these factors traditional in-patient care tends to be placed outside the hospital setting and be carried out at community level. In countries with a developed health culture, professional nursing care in the home is considered an approved form of care not only for material but also for more humane reasons. A nursing service system that is run properly may be taken for a political issue since the service provided can go a long way towards increasing the satisfaction level of the population. The timeliness and necessity of establishing home nursing care services were induced not only by changes in the structure of health care but were also urged by society itself. The health condition of the Hungarian population has gradually been deteriorating since the 60s. It is common knowledge that the mortality rate in the active age groups has increased whereas life expectancy at birth has decreased. As a consequence of the high mortality and low birth rate the population is steadily and increasingly declining. The age structure of the population is unfavourable, the number of those over 60 has grown and the number of people with disabilities considered as inactive has considerably increased. Home nursing care has in fact emerged as a new form of health care in the health service structure, which form already exists in countries with a well-developed healthcare service Home nursing care is intended to avoid taking the patient to hospital as much as possible, especially if adequate conditions can be created to look after the patient in the home. However, it is desirable that those who are taken to hospital should return to their home as soon as possible and on the basis of a medical indication should get the required nursing care. Moreover, there is a possibility of the patient having access to certain types of special therapeutic services, such as corrective-gymnastic therapy, speech therapy, physiotherapy. The purpose of developing home nursing care services is to change the expensive hospitalcentred structure of nursing care, to provide the opportunity for those most in need to recover from their illness in the home under humane circumstances receiving holistic care. This new service will in the long term contribute to strengthening the gatekeeper function of the family doctor s practice and to developing the area of community care

5 Summary of research procedure In order to adequately support the doctoral thesis entitled Development of professional and moral recognition of graduate nurses, we did research into the development of the career of nursing professionals who graduated from college. This was the first phase of our research. The results of this research made it possible for us to start a development programme on teaching and methodology. Consequently, it was in the second phase that we started to develop field practice for college students on primary health care and community nursing care introducing a mentor nurse further training programme, organising it on two occasions. The programme provided one-week, forty-hour further training for nurse mentors who in this way become involved in conducting regular/full-time students practice through family doctor practices. The establishment of the mentor nursing system in the primary care practising places at the Faculty of Health Care was made possible by the colleagues working in primary health care and prepared for the task in the further training programme that we organised. The research study actually helped us develop a new network for conducting practice to support college students doing their practice in primary health care. In the next second phase we also examined the opinion of health professionals working in community care about the applicability of their knowledge in practice gained in graduate training and about possibilities for success. A determining element of the study was exploring the demands crucial to developing nursing and further training. I drew my conclusions from studying the circumstances of the professional development of those working in the field of home nursing care, with special regard to the results of the research done into the possibilities of developing nursing and further training and I drew up my recommendations worth considering in both the BSc and MSc two-cycle nurse training programmes or when it comes to organising professional further training. Similarly, all the teaching methods that may serve the purpose of teaching primary and community care in everyday practical training are summed up

6 1st phase of research: development of professional and moral recognition of graduate History of research At the Faculty of Health Care Semmelweis University (formerly Postgraduate Medical University, then Haynal Imre University of Health Sciences) registered nurse training started on a full-time basis in In developing the programme (the end of the eighties, the beginning of the nineties), besides the experiences of the representatives of the national professional organisations, recommendations from the European Community or experiences from other parts of the world, mainly North America, were taken into account. The first fulltime year that graduated from college started work in Over the last thirteen years a total of 1577 degrees in nursing have been awarded in Budapest. Almost one third of the graduates were regular full-time students. At present there are 11 cities in this country where registered nursing training takes place at college level: four-year full-time or correspondence courses, with the college faculties of six universities teaching nursing as an independent programme which provides broadly-based general and specialised nursing knowledge. Aim of research The working team of the Nursing Institute conducted a study among full-time graduate nurses (target group) for seven years between 1994 and The aim of research was to explore the professional progress of graduate colleagues, to examine the professional and moral recognition of graduate nurses or the reasons why graduates leave or change their career. The study aims to explore which are the factors that influence graduate students in choosing a field or place of work? what circumstances, factors influence graduate students to leave or change their career? where, in what areas do graduates find jobs and why there of all places? Hypothesis and method of research I suppose that full-time nurse graduates are influenced in choosing their workplace by their experience gained in field practices. I suppose that leaving their career is influenced to a greater extent by lack of professional and moral recognition rather than financial considerations. I suppose that they opt to a great extent for non-state or social services in health care

7 A total of 250 structured questionnaires were sent to the target group, i.e. to nurse graduates who graduated in the time period examined. The questionnaires contained 25 questions, of which 13 were closed and 12 were open ones, and were completed on a voluntary basis, anonymously. The total number of questionnaires returned was 99, which means that the response/return rate was nearly 40%, but of the questionnaires 94 were only assessable. So the number of participants in the survey is n=94. This population on a national scale is 10% of the full-time graduates (of the nearly 1000 students who graduated in the time period examined), and 34% (of 288 students) in relation to the graduate nurse programme of the Faculty. Results, discussion, conclusions As a result of the questionnaire survey research carried out among graduate nurses, it is understood that choosing the first workplace was greatly (54%) influenced by positive (38%) and negative (16%) field practice experiences. For several years, efforts have been made by all professionals teaching special subjects at the College to achieve the highest level possible in organising field practices. This demand has been strengthened considerably by the integration process taking place between Semmelweis University and our Faculty and also by the Bologna Declaration. At the same time, this has created a new possibility for field practices, practices in primary health care to be organised and implemented more efficiently in order to meet more demanding tasks. The reason for starting nurse mentor training is that more and more students are expected to spend their practice in primary care. Nurse mentors trained at such high level could guarantee the extension of practising areas and an improvement in raising the standards of practices. This research confirmed that the great majority of respondents mentioned financial reasons as the primary factor for leaving and changing their career. This conclusion is confirmed by the facts encountered in the research exploring the more and more obvious presence of the private sector in the employment of graduate professionals. As a matter of fact, colleagues expect a better financial situation, moral recognition and not least success in their career from non-state or non-public sectors. The field of primary health care and home nursing care is almost totally out of control of state or local government ownership. So we are justified in saying that besides hospital and outpatient care, striving for independent professional fulfilment may be a decisive factor in choosing a career. The nursing image is a topic that the profession has been concerned with for decades. What is more often talked about is the shortage of nurses. The topic is discussed, reviewed, various committees, professional organisations carry out studies on it, but hardly any change - 7 -

8 can be experienced in the positive sense and only sporadically. This is probably because suggestions primarily come from groups that can be considered to be outside the nursing profession (the media, doctors, sponsors etc.). If, however, the profession themselves develop proposals concerning graduate nurses and urge drastic changes, then the chances will be greater for the prestige of the nursing profession including college graduates to rise. Professional nursing civil organisations, (such as the Hungarian Nursing Association, the Hungarian Home Nursing Care and Hospice Association), the public body of professionals established in 2004 (the Chamber of Hungarian Healthcare Professionals), the direct advisory panel of the Minister of Health (Nursing Professional Board), reorganised also in 2004, can play an important role in this matter. Application of the findings of research 1 in teaching: Establishment of a nurse mentor system in field practising places of primary and community care History of developing the nurse mentor system The Ministry of Welfare Phare Programme Bureau made a great contribution to developing health care in Hungary with special regard to primary health care. One of the main directions of changes was the training and further training of professionals both working in and teaching primary care. Several nurses participated and obtained a certificate in training programmes: two nurses in the Training, Further Training and Development subprogramme of the Phare HU Health Primary Care Programme in the University of Exeter Master programme in England and four nurses in the English language nurse mentor training programme organised in Hungary. The latter programme took place in collaboration with the Health Faculties of the Universities at Exeter, Nijmegen and Dublin. Two lecturers from our Nursing Institute attended both programmes respectively. With the trained lecturers collaborating, 20 nurse mentors received training in Hungarian following the English language nurse mentor training. There are only six of them working in Budapest in the County of Pest. Phare-organised training courses ended in the summer of Reasons for starting the nurse mentor system at the Faculty of Health Care Graduate nurse training has been done since 1989 on the correspondence courses and since 1990 on the full-time courses. In the second half of the nineties distance learning methods were adopted for the training courses. The number of students rose dynamically until the turn - 8 -

9 of the millennium, but since then there have been signs of stagnation. Professional field practices are now taking place in Budapest and in the County of Pest. The reason for starting nurse mentor training is that more and more college students (mainly graduate nurses) are expected to spend their practice in primary care. Specially and adequately trained nurse mentors can be a guarantee for the extension of practising areas and a strong improvement in raising the standards of practices and last but not least for the continuity of the competence and professional development of nursing specialists working in primary and home nursing care. Our intention was that mentor trainers we prepared here should help achieve a rising standard of the professional practising places that are asked to conduct practices. Suitable primary care practising places are capable of raising our students interest in this area of health care so that more and more graduate nursing professionals are expected to find jobs both in primary and home nursing care. Appropriate professional qualifications are likely to raise the quality of patient care in this sector as well. Further training programme We launched our nurse mentor training programme in the academic year of 2002/2003 involving doctor and nurse mentor trainers, teachers/lecturers at Semmelweis University, Faculty of Health Care, as well as some staff members from Semmelweis University Family Doctor Department, the National Primary Health Care Institute and the National General Public Health Medical Officer Service. The programme was implemented through the Ministry of Education Higher Education Programme-financed Invitation to Tender, as well as the further training programme sponsored by the Ministry of Health Healthcare Vocational Further Training Committee. The doctor and nurse mentor trainers cooperating in the programme participated on the educational and methodological course abroad and the mentor trainer course here in Hungary in 1998 as a result of strict selection. They have been enlarging their knowledge during their work experience and training ever since. International references, teaching materials of the British and Hungarian family doctor programmes and the experiences gained from earlier findings of the research conducted among students served as the basis for drawing up the topics for the five-day, fortyhour further training course. As a result, the programme comprised five topics: Healthcare systems in Europe; Teaching theories in nurse training; Nursing, medical consultation, advice; Team work in practice; Teaching programmes Conducting practice

10 Teaching methods for the further training programme In the training we intended to use the experiences of the British educational and methodological training. It is difficult to answer the question what method should be used in teaching or how to transmit the information to professionals in the primary care team. Besides traditional methods, modern endeavours had to be utilised and new modern methods based on them will have to be used. One of the novelties of this further training results from the fact that professionals employed in primary care ideally work in teams. Consequently, this multidisciplinary aspect should be reflected in their further training. Also, it is essential to know the features of adult training since entirely different methods and means of encouraging are needed to effectively involve these people. Traditional, lengthy lectures in adult training seem to be ineffective in the long run. Instead, it is methods that require small groups, problem and evidence base, reflective learning, common/creative thinking, cooperation, critical reading, critical writing, critical incident that will have the desired effect. These new teaching and learning methods will contribute to improving the efficiency and quality of medicinal and paramedical education and at the same time to ensuring better patient care. Mention should be made that besides these new educational and teaching methods, better use must be made of the possibilities of informatics in education a significant part of which results from the global spread of the Internet and easier and easier accessibility of a number of nursing professional news sites (home page) and electronic data base. 2nd phase of research: investigation of the professional development of specialists working in the field of home nursing care Aim of research Given the development of the system of home nursing care, it is worth thinking about how hospital-centred nurse training traditional both in theory and practice will be able to meet the new demands and expectations and how students will be able to succeed in this field of specialisation. The benefits of the study show that curricular development in the two-cycle training system (BSc) nursing and patient care basic programme will be based on a real needs survey in terms of community care and related topics. Further benefits are that further training programmes to be organised by the College of Health Care/Faculty of Health Sciences will also be based on a real needs survey of nursing professionals

11 The study aims to explore how home nursing care in this country will be able to meet the new needs and expectations of our age, how our graduate colleagues will succeed in this field of specialisation, how colleagues working in this field look at the possibilities of developing further training. Hypotheses of research I assume that because of the multiplicity of nurse training students are unable to obtain specific theoretical and practical knowledge and experience of home nursing care within the given time frame of training despite the fact that the college graduate nurse training curriculum contains teaching the subjects set out in giving justifications for conducting the research. I assume that they were unable to acquire the elements of home nursing care during their training. In addition, I assume that a lack of professional knowledge mentioned already made it difficult for students to start work and adjust to conditions professionally and personally in a hospital setting. Persons to be involved in this research were: Students who graduated from full-time courses of Semmelweis University, Faculty of Health Care who are employed full time or part time in home nursing or community care. Professionals working full time or part time in home nursing care services. Their involvement in all programmes was all the more important since they are registered as field practising places in both the NQR and college programmes. Their opinion is important with respect to developing nurse training. Students involved in the research were reached through their list of addresses made available by the Registrar s Office of Semmelweis University, Faculty of Health Care. In order to supply students data, permission of the Dean was needed. According to the original research plan, I had wanted to conduct the survey at all college faculties. In the course of preliminary oral requests, however, some difficulty in performing the research study arose; namely the fact that some of the newly integrated college faculties and new university leaderships do not allow recent or former graduates to be reached for any purpose of research. In this situation I

12 developed alternative approaches to the successful availability of colleagues. Finally I managed to reach the services through the member organisations of the Hungarian Home Nursing Care and Hospice Association and the municipal and departmental inspectorates of the National General Public Health Medical Officer Service. The registration of the National General Public Health Medical Officer Service is up to date, for these are the professional inspectorates that issue operating licences for services and supervise their activities. Sample features Of the 213 questionnaires received I only managed to use 190 in assessing and analysing them since prior qualification in clinical professional nursing or being registered as a nurse in the National Qualifications Register was a prerequisite of involvement in the survey. Consequently, those who filled in the questionnaire as physiotherapist or physicotherapist assistant graduates referring to work experience gained in the field of home nursing care could not be involved. Accordingly, the number of elements became 190 persons. The distribution of rate of those involved in the survey was: graduate nurses 20%, graduate nurses registered in the NQR 35%, clinical professional nurses graduates also registered in the NQR 45%. 42 % of the sample attended full-time courses, 53% attended correspondence courses an only 5% acquired their knowledge via distant learning. Those asked in the survey work in the capital and this sample represents the national distribution of services since 17% of home nursing care services can be found in the capital. 58% of the respondents perform their nursing activity in cities, 27% in rural settings. Only 58% work in their professional job full time, 42% perform part-time jobs. Colleagues (n=79) who are engaged in part-time jobs in some of the home professional nursing care services, first of all work full time in some of the inpatient care institutions. Besides these, the majority perform their duties in outpatient care centres. Results, conclusions, proposals The study provides guidance on the area of postgraduate training for professionals engaged in teaching and further training. The new credit-based, two-cycle nurse training BSc programme introduced in the 2006/2007 academic year provides a good opportunity for curricular development in the basic programme and for changes in the contents of teaching materials. The responses of those asked in the survey show that in the teaching of some special subjects the issues, problems of community care as a new special field are not adequately dealt with. Scenes of field practice only provide little possibility for practising knowledge,

13 acquiring skills within the time frame of training. This is why development should be carried out in two directions: one is the review of the graduate programme and making the required changes there, the other is developing knowledge in terms of professional further training. Research results show that there is a great demand and willingness among those working in community care for organising (mainly one-day) professional further training courses. Among the topics priority is given to wound care, stoma and laryngeal cannula treatment, as well as performing other tasks involved in professional care (24%). There is also a need for topics, such as obtaining the ability to apply patient mobilisation techniques and rehabilitation knowledge (20%), as well as deeper insight into the field of elderly care and hospice care (16%). Similarly in the focus of attention are patient support, communication and personality development which should be implemented in graduate training and should be extended in professional further training. As a further alternative option, the introduction of a new specific professional subject has come into the foreground, just like curricular development in the nurse BSc programme in the field of Basic care community nursing contact lecture and field practice, as well as in the contents of other subjects. Some of these subjects like Basic care community nursing and the circumstances, possibilities of developing field practices will be discussed more in detail in the next paragraph. In the last decade, changes that have taken place in the structure of Hungarian society and in the financial situation of the population highlight the treatment and laying the foundation for forms of local community care through a sociological approach. It is therefore important to complete and add new elements to the topics of sociological and socialpsychological subjects. Nursing care in a home setting requires special psychological knowledge and its application. It is important to emphasise the review of the issues of psychology (patient support) in the training period. In the programme special emphasis must be placed on the psychological aspects of giving adequate information to patients since this goes a long way towards the good work of the nursing team. The application of primary prevention techniques also contributes significantly to correctly implement everyday nursing practice. To the same extent, this requires special knowledge on the part of those performing informative and educational work outside the hospital setting, in the local community and in the family setting. This is why it would be important to evaluate the basic criteria of health education (advice on lifestyle) in a home setting and to practise them in simulated or real circumstances in the process of becoming a nurse

14 I would consider it just as important to lay the foundation for a certain group of topics and, of course, to extend them in professional further training. So these topics should more specifically comprise legal (concluding a contract, patient rights, patient information and documenting), ethic (professional secrecy, patient information) and financing (contract terms & features) knowledge within the range of health management, health economics, or other subjects. As a matter of fact, such knowledge is indispensable in home patient care. Significant lack of knowledge would already necessitate guides to writing application letters in graduate training and widen this knowledge on further training courses. Application of the findings of research 2 as a teaching strategy The introduction of community care into nursing training. Curricular development in the twocycle higher education system in the nurse caregiver specialisation When the first curriculum of college nurse training was elaborated, there was not enough domestic theoretical and practical experience concerning the system and methods in this matter. So the first curriculum was based on the traditions and experiences of the nurse training events that have been taking place since 1975, with this training form still bearing the marks of secondary schools where students receive special training in nursing. Soon after the first year started, the demand already arose for making changes in and developing the methods of both theoretical and practical training. In the past 17 years of nurse training, the training programme was revised and appropriate upgrading was carried out in it, including important issues of primary and community care. One of the essential elements of curricular development most detectable among these closely related topics was that we increased the number of general and special nursing lectures, and also the number of hours in field practice. Besides the increase in the number of lectures/hours, developing content standards was also a decisive element of curricular development. The first curriculum of full-time students was modified in 1993, and then another modification took place in The next development activity was carried out when the European Credit Transfer System was introduced in This time we managed to make the nursing aspect even more emphatic retaining former values and traditions and focused our attention on the development of field practice. Suggestions made in the first research phase were finally used, which helped raise the standard of directed practising places by establishing teaching districts. The establishment of practising places made yet another contribution to the introduction of students into some specialities of community care

15 Establishing two-cycle programmes was the last stage of development when besides Primary care the subject of Community care was introduced. This renewal of our programmes meant a change in content and the way of thinking rather than a mere change in naming a particular subject. And along with these alterations, we continued our field practice development work begun earlier. As a result, community care appeared as an independent area of practice, which made it possible for students to perform guided tasks synthesising all that they had learnt in the previous seven semesters. Announcements relating to the thesis topic 1. Nosza, M., Balogh, Z. (figure): Problem solving in the Nursing Processe. Nővér 1992;5(2-3): Balogh, Z: A hemiplegic patient rehabilitation at the home care system. Nővér 1995;8(6): Nosza, M., Balogh, Z.: Community-based Nursing nursing at the community. Háziorvosi Szemle, Háziorvosi Szemmel Melléklet 1996;3(4): Balogh, Z.: PHC system in the UK. Háziorvosi Szemle, Háziorvosi Szemmel Melléklet 1996;3(4): Modly, D., Zanotti, R., Poletti, P., Fitzpatrick, JJ. (edit) Home Care Nursimg Services. In: Balogh, Z., Modly, D.: Home-Based Health Care in Hungary. (Chapter 12) New York, USA Springer Publishing Company, Inc.; p Balogh, Z.: Course of the Education Methodology in the Exeter University. Nővér 1998;11(1): Balogh, Z., Némethné Molnár P., Papp, K.: Countinuing education ath the Hungarian PHC System basaed on the UK experiencies. Nővér 1998;11(1): Balogh, Z.: Perspectives of the community care in the Europe. Ápolásügy 2000;13(2): Balogh Z.: Swedesh experiencies. ETInfo 2000;3(6): Balogh, Z., Papp, K.: Evidence-based Nursing at the practice. Ápolásügy 2001;14(2): Balogh, Z.: Nursing Education in Hungary. Egészségügyi Menedzsment 2001;3(2): Balogh, Z.: Nursing literature in electronic form. Nővér 2001;14(4): Balogh, Z.: Theories about the article titled Who teach nurses? Nővér 2002;15(1):

16 14. Balogh, Z.: The roles and opportunities of the BSc degree nurse at the Hungarian Health Care System Recept 2002;13(3): Dr. Zrínyi, M., Balogh, Z.: Student Nurse Attitudes Towards Homless Clients Nővér 2002;15(1): Dr. Mészáros Judit, Balogh Zoltán: Professional and moral esteem of bachelor degree nurse. Orvosképzés 2002;77(4): Balogh, Z.: Evidence-based practice guidelines for nursing and rehabilitation of stroke patients. Lege Artis Medicinae 2003;13 (1): Dr. Zrínyi, M., Balogh, Z.: Student Nurse Attitudes Towards Homless Clients Lege Artis Medicinae 2003;13 (4): Balogh Zoltán: Experiences of the Stroke Audit. Ápolásügy 2003;16(4): Zrínyi Miklós, Balogh Zoltán: Student Nurse Attitudes Towards Homless Clients: a chalange for education and practice. Nursing Ethics 2004;11(4): Balogh Zoltán, Papp Katalin: Toward Active Old Age Introduction of the Leonardo da Vinci Community-based Project. Ápolásügy, 2004;7(2): Balogh, Z., Dr. Mészáros, J.: Pflege von Patienten mit Schlaganfall, Heilberufe Das Pflegemagazin (Deutschland), 2004;56(5): Papp, K., Balogh, Z.: 2006;19(6): Dr. Mészáros, J., Balogh, Z., Dr. Zékányné R. I.: Nővér 2006;19(6): Dr. Gödény, Sándor (edit): Developmnet of the Clinical Effectiveness at the Health Care. (Balogh, Z.: 13. chapter, ) Pro Die Kiadó, Budapest, Balogh, Z.: Prevention and careing at the GP practice. Hivatásunk 2007;2(2): Balogh, Z., Dr. Csák, R.: Common problems-pictures about German Nursing and Health System. Hivatásunk 2007;2(2): Balogh, Z., Kökény, M.: Influencing nursing policy in Hungary Organization of hospice care. Jihoceska universita v Ceskych Budejovicích, Zdravotne sociální faculta, p , Nové Trendy v Osetrovatelství - VI. Jihoceské osetrovteské dny (Új trendek az ápolásban VI. Dél-Bohémiai Ápolási Nap, szeptember 20-21)

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