Establishing the contribution of nursing in the community to the health of the people of Scotland: integrative literature review

Nurse navigators and person-centred care; delivered but not valued?

Positioning the individual at the centre of care (person-centred care [PCC]) is essential to improving outcomes for people living with multiple chronic conditions. However, research also suggests that this is structurally challenging because health systems continue to adopt long-standing, episodic care encounters. One strategy to provide a more cohesive, individualised approach to care is the implementation of the nurse navigator role. Current research shows that although PCC is a focus of navigation, such care may be hindered by the rigid, systematised health services providing siloed specialist care. In this paper, we utilised a case study method to investigate the experiences of a nurse navigator and patient. The nurse navigator and the patient participated in individual interviews, the transcripts of which were analysed using critical discourse analysis. Findings from a larger research project suggest that traditional measures (hospital avoidance, emergency department usage) which work as the service objectives of the nurse navigator service have the potential to stifle the delivery of PCC. The analysis from this case study supports the broader findings and further highlights the need for improved alignment between service objectives and the health and well-being of the individuals utilising the services.

Community nursing middle management: 'dealing with different people in different time zones on both sides'

The overall aim of the investigation was to redress a knowledge gap by exploring community nursing middle managers' (CNMMs') experiences of role enactment through change within Community Health Partnerships (CHPs) in Scotland-now further evolved into Health and Social Care Partnerships (HSCPs). HSCPs play a key role in shifting care from the acute to the primary care/community setting. However, a literature review demonstrated there has been very little research into the role of CNMMs within the changing primary care context. This concept was considered important in understanding how CNMMs enacted their roles to implement service change. A qualitative longitudinal interpretative phenomenological analysis (IPA) ( Smith, 1996 ) study was conducted in four distinct phases, comprising the reflexive, foundational, recursive and expansive, from 2008-2011. Some 35 semi-structured interviews were conducted with 26 participants. CNMMs perceived that their responsibilities had increased, become more complex and wider ranging. Maintaining an implicit connection with service users was a primary motivation for CNMMs. They were proud to be members of the nursing profession aligning their identity with their career history. A small but significant proportion resigned during the study and some were considering leaving the NHS. The study addresses a gap in literature, contributes to the understanding of NHS community nursing, middle management, role, change and gives a voice to CNMMs in Scotland. They are the lynchpins in taking change forward and maintaining quality services. Much more attention needs to be paid to the needs, constitution and sustenance of middle managers in Scottish community nursing-which has policy, practice, education, and research and retention implications.

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

Background

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps.

Methods and findings

An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals.

Conclusion

A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work.

Systematic review registration

International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

Case management: developing practice through action research

This article is a report of an action research study carried out with community nurses to help develop case management within their practice. Using action research principles, nurses reviewed and analysed their current practice and developed recommendations for further embedding case management as a means of supporting patients with complex care needs in their own homes. Findings indicate that a number of factors can influence the community nurse's ability to implement case management. These factors include approaches to case finding, availability of resources and interprofessional working. Important considerations for nurses were the influence of the context of care, the geographical location and the health needs of the local patient population, which meant that case management may need to be adapted to meet local circumstances.

Community nurses' participation in palliative care research: the Dignity Care Pathway

Evidence-based practice is a cornerstone of modern health care. Ongoing challenges have been identified in the strength of the evidence base in community palliative care nursing (Walshe and Luker, 2010). This paper discusses the participation of community nurses in a palliative care research project. The Dignity Care Pathway (DCP) is an evidence-based framework developed using a collaborative research approach with community nurses in Scotland. Collaborative research has been advocated as one way to facilitate integrated knowledge transfer and to address the research-practice gap. The aim of this paper is to discuss the participation of community nurses in a collaborative research project to implement a palliative care intervention in practice. The discussion will draw on findings from the third phase of the DCP multiphase research project.

Developing and implementing the community nursing research strategy for Wales

In order to obtain the best patient outcomes in community nursing, practice needs to be underpinned by robust research-based evidence. This article describes a Community Nursing Research Strategy developed and implemented in Wales to provide the nursing profession with the evidence to support future organisational and professional change in achieving excellence in the community. This was developed in partnership with education, research, health services, workforce planning and Government using consensus methodology (specifically, a nominal group technique). Consequently, the process was inclusive and included three steps: escalating presentation of ideas, topic debate and topic rating. The result was a strategy with four implementation strands, including a virtual network, research portfolio, application to practice and leadership.

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: the Fremantle Diabetes Study

BACKGROUND

Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes.

OBJECTIVE

To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting.

DESIGN

Prospective observational study utilising data linkage.

SETTING

Postcode defined region in Fremantle, Australia.

PARTICIPANTS

All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996.

METHODS

Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs.

RESULTS

During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9-85] visits, range 1-1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes.

CONCLUSIONS

Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.

Social meanings and understandings in patient-nurse interaction in the community practice setting: a grounded theory study

BACKGROUND

The patient-nurse relationship is a traditional concern of healthcare research. However, patient-nurse interaction is under examined from a social perspective. Current research focuses mostly on specific contexts of care delivery and experience related to medical condition or illness, or to nurses' speciality. Consequentially, this paper is about the social meanings and understandings at play within situated patient-nurse interaction in the community practice setting in a transforming healthcare service.

METHODS

Grounded theory methodology was used and the research process was characterised by principles of theoretical sensitivity and constant comparative analysis. The field of study was four health centres in the community. The participants were patients and nurses representative of those attending or working in the health centres and meeting there by scheduled appointment. Data collection methods were observations, informal interviews and semi-structured interviews.

RESULTS

Key properties of 'Being a good patient, being a good nurse', 'Institutional experiences' and 'Expectations about healthcare' were associated with the construction of a category entitled 'Experience'. Those key properties captured that in an evolving healthcare environment individuals continually re-constructed their reality of being a patient or nurse as they endeavoured to perform appropriately; articulation of past and present healthcare experiences was important in that process. Modus operandi in role as patient was influenced by past experiences in healthcare and by those in non-healthcare institutions in terms of engagement and involvement (or not) in interaction. Patients' expectations about interaction in healthcare included some uncertainly as they strived to make sense of the changing roles and expertise of nurses and, differentiating between the roles and expertise of nurses and doctors.

CONCLUSIONS

The importance of social meanings and understandings in patient-nurse interaction is not fully apparent to nurses, but important in the patient experience. Seeking understanding from a social perspective makes a contribution to enhancing knowledge about patient-nurse interaction with subsequent impact on practice, in particular the development of the patient-nurse relationship. The implications are that the meanings and understandings patients and nurses generate from experiences beyond and within their situated interaction are pivotal to the development of their relationship in the transforming community healthcare environment.

Exploring leadership in community nursing teams

AIMS

This article is a report on a study investigating how leadership is perceived in community nursing teams and how these perceptions are translated into working practices of team leaders.

BACKGROUND

The consensus in community nursing literature is that leadership is important, and especially so in a time of change. However, little empirical evidence exists on how leadership works in practice.

METHOD

The study adopted an exploratory descriptive design, utilising individual semi-structured interviews and focus groups in four case-studies, with a total of 54 participants. Two case-studies focussed on district nursing teams and two involved public health nursing teams, located in two geographical areas. Participants debated their understanding of the concept of leadership, its associated practices and behaviours in teams, if they saw themselves as leaders, and what preparation was required. The study was undertaken in 2009. Framework analysis techniques were employed to analyse the data.

FINDINGS

A 'quasi-family' model of leadership emerged, with significant emphasis on the importance of personal relationships and support. Nursing grade had a greater impact on perceptions of leadership than geographical context or professional and clinical focus.

CONCLUSION

No clear fit with any existing theoretical framework was identified. However, nurses in the highest grade banding, in particular, demonstrated practices associated with transformational leadership. Nurses expressed the very clear need to be acknowledged, respected and valued, and that those who provided this support were regarded as good leaders.

Professional boundary work in the face of change to generalist working in community nursing in Scotland

AIM

The present study explored how community nurses and managers constituted changes towards generalist working.

BACKGROUND

Following international trends moving from acute care towards community care, changes within community nursing in the United Kingdom have been subject to debate in recent years. Sociological insights into 'boundary work' in professional disciplines are informative for understandings about proposed new roles in community nursing. Recently, radical changes to the role of the community nurse from specialist disciplines to a generalist community health nurse model were proposed in Scotland and tested in four health boards.

METHODS

Focus group discussions were held with 27 community nurses and semi-structured interviews with three managers during January-March 2009 in a purposive sample from one health board. Discussions were audio-recorded and transcribed verbatim. Initial thematic analysis was used to highlight key themes from the data and later a discursive analysis focused on the rhetorical strategies used by participants.

FINDINGS

Four key themes were identified along with the rhetorical devices associated with these including: the undermining of the generalist model through the 'jack of all trades, master of none' metaphor through associations of loss of specialisms; how the re-establishment of specialist discipline boundaries occurred; how current roles were validated and how managers and nurses accounted for future changes to the profession.

CONCLUSION

The qualitative study explored here has implications for discussions about future role change debates within community nursing as well as the specialist-generalist debate internationally. Managers and policy-makers involved in organizational changes are required to give greater credence to the perceived professional status of community nursing.

Investigating the contribution of community nurses to anticipatory care: a qualitative exploratory study

AIMS

To investigate how one aspect of anticipatory care is understood and delivered in practice. 'Anticipatory care' in this context can be understood as proactive care, which is oriented towards prevention of adverse events.

BACKGROUND

Scotland has identified the intention to move away from a preoccupation with acute care and invest in health improvement and anticipatory care. Community nurses are the key, yet little is known about how they understand and deliver anticipatory care.

METHODS

A qualitative case study design using individual in-depth interviews (n=10), observation (n=9) and focus groups (n=5) was selected. Five focus group interviews were carried out with district nurses, practice nurses and health visitors. Subsequently, nine observation events took place, each focused on a single nurse/client encounter. Data were collected during 2008 and 2009 in one Community Health Partnership in Scotland.

FINDINGS

Two approaches to anticipatory care emerged; these were influenced by participants' roles and responsibilities. Approach 1 derives from Government policy agenda and is focused on protocol-focused management of long-term illness. Approach 2 is synonymous with long-standing nursing activity focused on holistic care of individual patients. Both approaches are proactive in nature.

CONCLUSIONS

There is scope to develop a more conceptually complex model of anticipatory care, building on this initial exploration, within which all aims, roles, practices and methods of evaluation can be located and clearly visible. This offers the potential to enable practitioners to interpret and apply policy--otherwise change may be limited and result in service gaps.