Continuous and Integrative Nursing and Palliative Care


Clinical Module

Holder of subject:

Dr Antonija Poplas Susić, Professor

Education providers:

  • Dr Antonija Poplas Susić, Professor
  • Dr Mateja Bulc, Assistant Professor
  • Dr Marija Petek Šter, Assiciate Professor
  • Dr Davorina Petek, Assistant Professor
  • Dr Mitja Košnik, Professor
  • Dr Polona Selič, Assistant Professor
  • Dr Jerneja Farkaš Lainščak, Assistant Professor
  • Dr Danica Rotar Pavlič, Professor
  • Dr Janez Rifel, Assistant Professor

Contact hours - lectures:


Contact hours - seminar:


Contact hours - exercises:


Individual student work:




Level of study:

Second cycle study program Nursing





Subject specific competences:

Objectives for continuous and integrated health care of chronic diseased are:

  • to become acquainted with the philosophy, models and organization of continuous integrated health care;
  • to learn the basic principles and ethical dimensions of continuous and integrated health care provision;
  • to learn about the principles and importance of continuous integrated health care in respect to patients’ and their families’ quality of life;
  • to thoroughly learn about chronic diseases and their impact on the society;
  • to learn about the organization of other systems, services and the legal framework important for the implementation of integrated health care;
  • to learn about ways of supporting the partnership between patients and health care professionals;
  • to learn about the organization of the health care system in detail;
  • to learn about the integrated and multidisciplinary team approach in continuous health care provision;
  • to expand the existing knowledge on stages of continuous and integrated health care (admission, discharge, institutional care, treatment of patients in the home setting, community care, long-term care) and the role of different health care professionals;
  • to improve professional communication skills in continuous and integrated care provision;
  • to learn about the economical influences of chronic patients’ care and the influences of integrated health care on the efficiency of health care provision;
  • to learn about informational systems supporting the implementation of continuous and integrated care;
  • to learn about the importance of including lay health care providers in the provision of continuous and integrated health care.

Students gain knowledge and understanding of:

  • the development and placement of palliative care in the health care system;
  • ethical dilemmas and ways of solving them in palliative care;
  • most frequent communication skills in palliative care;
  • principles of pain management, management of gastroenterological, neurological, psychiatric, urogenital and respiratory symptoms;
  • principles of nutrition and hydration in end-of-life care;
  • specific management of wounds and mouth care in end-of-life care;
  • comprehensive care for dying patients in the home setting;
  • the importance and efficiency of using treatment protocols in the treatment of chronic patients;
  • management of psycho-social problems;
  • organization of palliative care network within the health care system;
  • principles of research in palliative care, especially the role of qualitative research methods;
  • the importance of informational technologies in palliative care;
  • the importance of prevention, medication treatment, and keeping chronic patient registers;
  • understanding multimorbidity and the importance of cooperation between health care providers, patients, and their family members.

Mandatory and recommended references:

Mandatory references:

  • Textbook in Palliative Nursing, editors: Betty Ferrell, Nessa Coyle, New York, 2005
  • Billings J, Leichsenring K.(Eds). Integrating healt and social care services for older person. Viena: Ashgate Publishing Limited, 2005.
  • Ebersole P, Hess P, Theris T, Jett K. Gerontological nursing and healthy aging (Second edt.). Elsevier Mosby: St. Luis, 2005.
  • Leichsenring K, Alaszewski AM. (Eds.). Providing integrated health and social care for older persons.Vienna: Ashgate Publishing Limited, 2004.
  • Haber D. Health promotion and aging. Practical applications for health professionals (third edition). Springer publishing company: New York, 2003.
  • Hinchliff S, Norman S, Schober J. Nursing practice and health care (4 th edt.). Arnold: London, 2003.
  • Kendry MJ. What every case manager should know. Case Management. 2004;9:49-50.
  • Minkman MMN, Schouten LMT, Huijsman R. et al. Integrated care for patients with a stroke in the Netherlands: results and experiences from a national breakthrough collaborative improvement project, 2005.
  • NHS Modernisation Agency and Skils for Health. Case Management Competences Framework. 2005,
  • Peternelj A. Novi pristopi v organizaciji celostne obravnave bolnika – integriran pristop. V: 4. golniški simpozij: Zbornik predavanj; Golnik, Brdo pri Kranju 14 – 15.oktober, 2005.
  • Peternelj A. Izvajanje programa neakutne obravnave v KOPA – Golnik. Bilt Ekon Org Inf Zdrav. 2005;21(1):11–8.
  • Supporting people with chronic disease in Europe: the role and contribution of nurses. Geneva: World Health Organization, 2003.
  • Vaarama M, Pieper R. (Eds.). Managing integrated care for older Persons. European Health Management Association; Saarijärvi, 2005.

Recommended references:

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Conditions for the inclusion in the study:

Fully completed study obligations of 1st and 2nd semesters.

Assessment methods:

  • written examination – 60%,
  • individual project – 30%,
  • participation in workshops – 10%.

Teaching methods:

Learning and teaching methods will mainly consist of interactive workshops with project work and practical solving of typical situations, with emphasis on integrative approach and team work.
Firsthand training sessions will be organized in units and institutions locally and abroad where integrated care for chronic diseased and palliative care is practiced (Netherlands, Denmark, England, Sweden).