Early perceptions of the role of community matrons

VOL: 103, ISSUE: 23, PAGE NO: 32-33

Janet Armour, MSc, BSc, Dip Health Studies, RM, RGN

Community matron, County Durham Primary Care Trust

To ascertain current views, perceptions and ideas on the controversial role of community matron. ...

Abstract: Armour, J. (2007) Early perceptions of the role of community matrons. www.nursingtimes.net

Aim: To ascertain current views, perceptions and ideas on the controversial role of community matron.

Method: Quantitative data was collected using a postal survey distributed to a heterogeneous population (multidisciplinary team members) using a non-probability sampling technique across Durham Dales Primary Care Trust. Data was analysed using descriptive techniques (frequencies; median) and inferential techniques to investigate associations between observed frequencies (Chi-square) and differences between comparable groups using the non-parametric method (Kruskal-Wallis).

Results: Only a year after its introduction, the perceptions of the community matron role, key competencies and aims and responsibilities identified by respondents were the same as those outlined in the Department of Health competency framework (NHS Modernisation Agency and Skills for Health, 2005). Half of respondents perceived the role to have had an impact on patients living in Durham Dales.

Discussion: Although the conclusions are preliminary because of limited sample size in each variable, the study found statistically significant relationships between both locality and professional role and the early perceptions of the community matron role.

Conclusion: Overall, the survey suggests that, despite the role of community matron being in its early developmental stages within Durham Dales PCT, the majority of respondents are familiar with the role and their perceptions had not changed from when the role was introduced. Those who were initially unclear about the role and whose perception had changed stated that they had become more positive towards it as their understanding of the role became clearer.

Background

The NHS Improvement Plan (DH, 2004a) set out priorities for the next four years that highlight the importance of providing better support for people with chronic diseases (DH, 2005a). Along with self-management and disease management the document recognised the need to improve care for people with complex needs. A key part of meeting these personal needs was the introduction of high-quality and personalised case management through newly appointed clinical specialists, most commonly nurses, known as 'community matrons' (DH, 2004a).

The introduction of community matrons who could apply a case management approach was to play a significant role in helping local health communities improve care for patients with long-term conditions (DH, 2004a), and in helping to achieve the public service agreement target of reducing inpatient bed days by 5% by 2008 (Spending Review, 2004). This was considered by the government to be the first step to creating an effective delivery system and implementing the wider NHS and social care long-term conditions model (DH, 2005a).

Patients in this high-risk group not only need good management of their specific diseases (DH, 2004a; DH, 2005a; DH, 2005b) but also a holistic overview to be taken of their full health and social care needs (DH, 2005a). It is recommended that their care should go beyond the clinical to encompass the full range of factors that affect them, such as their ability to maintain personal interests and social contacts (DH, 2005a). In order to better manage long-term conditions within Durham Dales, the PCT employed four community matrons as part of a 'long-term conditions team' whose role would be to actively seek out and manage patients with highly complex needs. The long-term conditions team also includes two social workers and one public and patient involvement facilitator.

It was anticipated that, through joint working, the team would proactively case-manage those patients living in their own homes and communities who were intensive service users, thus reducing unplanned admissions caused by poor disease control and lack of effective prevention and social support (DH, 2004a). This required restructuring of current working patterns to produce a more flexible approach to long-term condition management that bridged the primary/secondary care divide.

Evaluating the new role

In May 2006 the community matrons had been in post for 12 months. Assessing perceptions of the effect of this new role on other healthcare professionals, services and ultimately patient care in the Durham Dales was seen as an essential part of developmental analysis. The government remains clear that community matrons, using advanced clinical nursing care and a case management approach, are the key to providing high-quality care for people with chronic disease (DH, 2006a). Measuring effectiveness is an important consideration for all involved in service provision and patient care, in particular the evaluation of new services that often incur set-up costs that are not offset by immediate financial gain.

Perceptions about the benefit of the community matron role continue to be mixed (Health Service Journal, 2004; King's Fund, 2005; DH, 2004b) and professionals within our PCT are no different. New nursing roles are often viewed with trepidation. Research suggests that the introduction of new roles often causes lack of clarity over practice boundaries; varying perceptions and understanding of the new role; uncertainty over how the new role fits within existing teams; and reports by staff of feeling threatened (Cummins et al, 2003). It is also recognised, however, that implementing new roles is an evolutionary process and the organisational changes required need time to become accepted.

As joint working is the key to providing a service to patients that is both efficient and effective (DH, 2006a), obtaining the views and perceptions of healthcare professionals of this new role was considered an important first step. The success of the community matron role relies on working across organisational boundaries to enable matrons and colleagues to collaborate in procuring and providing care for patients (DH, 2005c). This in turn is dependent on the understanding and acceptance of the role by other members of the multidisciplinary team.

Nationally, the community matron role is still in its early implementation stages. Fewer than half the target number of community matrons have been appointed (Nursing Times, 2007). As a result there is some anecdotal evidence but no real data available on the perceptions and views of other members of the multidisciplinary team. This provided the justification for the project.

Aims and objectives

Evidence provided by the literature review did not result in a hypothesis being formed and therefore this was an exploratory study. Ascertaining the perceptions and views of the community matron role - and how it integrates within the multidisciplinary team and service provision in Durham Dales - sits well with an evaluation research design, as its purpose is to assess the effects and effectiveness of this new innovation and service from the healthcare professional's perspective. Data was collected using a questionnaire and adopting a quantitative approach. The results are helping to further develop the role of the community matron and shape the structure and support mechanisms that will form the future of community nursing services in Durham Dales.

The objectives were as follows:

• To ascertain healthcare professionals' perceptions of the community matron role within Durham Dales PCT;
• To obtain the views of healthcare professionals on the role of the community matron within the multidisciplinary team;
• To identify areas where there is a lack of clarity and understanding of the community matron role among members of the multidisciplinary team in order to improve integrated working;
• To ascertain the key responsibilities and competencies required by the community matron to be an effective practitioner, as viewed by other healthcare professionals;
• To obtain the views of healthcare professionals on which factors and outcomes would best measure the impact the community matron role has on patient care.

Method

Studies in the literature review that examined the impact and effectiveness of a practice, service delivery and role were found to be both quantitative and qualitative in nature, often combining the two approaches to gain a more holistic view of the subject. Durham Dales covers a large area. To enable data to be collected from a wide variety of people spread over a large geographical area, the quickest, easiest, most cost-effective and practical way to collect data was to use a postal survey (Cormack, 2004).

Data was collected using a postal survey distributed to a heterogeneous population (multidisciplinary team members) using a non-probability sampling technique across Durham Dales PCT. Data was analysed using descriptive techniques (frequencies; median) and inferential techniques to investigate possible associations between observed frequencies (Chi-square test) and differences between comparable groups using a non-parametric method (Kruskal-Wallis).

Results

From a sample group of 218, 119 completed questionnaires were returned, giving an overall response rate of 55%. Community nursing sisters had the highest response rate (75%), followed by GPs (59%) and practice managers (58%). Several of the questionnaires had an occasional missing responses so some of the percentage replies do not add upto 100%. Key findings were as follows:

• Some 68% of respondents said they were clear about the community matron role and 43% (many of them GPs and nursing sisters) felt their perception of the role had not changed since its introduction. Some 83% of those whose perception had altered said that working with or alongside the community matron improved their understanding of the role, resulting in a much more positive view;
• To improve communication and thus reduce role duplication - in particular with community nursing teams - those who were unclear about the role suggested increased regular attendance by the community matron at the practice and providing information to multidisciplinary teams about their role;
• Although around half (54%) of respondents felt the role complements their existing role, community nursing staff made up the majority of those who did not;
• Significantly, community nurses provided the highest number of responses suggesting the matron should be placed in the community nursing team, and GPs the highest for placement into the practice team, with disagreement over whether the matron should be placed in a separate long-term condition team (as is currently the case) or be hospital-based;
• The key competencies required by the matron to be an effective practitioner were identified as a background in healthcare (100%); a nurse (88%) with community experience (82%); who is a clinician (82%) with advanced clinical skills (82%) and recognised leadership qualities (76%);
• The key aims and responsibilities of the community matron role were identified as: providing support and advice to patients and their families about long-term conditions (82%); improving quality of life (94%); and reducing unplanned admissions (91%);
• The factors identified as the best measures of the impact of the role were: reduction in unplanned admissions; enabling patients to stay in their own homes and communities; patients better able to manage their own disease; improved disease management;
• Half of respondents (50%) disagreed with the statement that the role had not had an impact, with a significant difference identified between localities;
• Almost a third of respondents provided additional comments, in particular those working in more rural localities, who felt the service would be more cost-effective if district nurses received appropriate training and skills to carry out case management.

Limitations of the study

With no similar studies to compare this study against, it was impossible to calculate a sample size that would provide the necessary statistical power. The low total numbers in each group (locality and professional role) were small for a quantitative research study. This factor, in addition to using an un-validated questionnaire, reduced the reliability of overall results, especially where a statistically significant difference was found. Despite this the survey did identify certain trends.

Discussion

The survey focused on three areas:

• The community matron role;
• The role of the community matron within the multidisciplinary team;
• Community matron aims and responsibilities.

The community matron role

As the community matron role requires a totally new type of practitioner (Bird and Morris, 2006) and is still in its development phases, it was surprising to find that 68% of respondents said they were clear about the role. This was higher than anticipated considering clarification of the role has only recently been released (DH, 2005d) and, more importantly, the community matrons themselves are only just beginning to feel comfortable and familiar with the role.

The vast majority of respondents (83%) suggested that as the community matron role began to evolve, and members of the multidisciplinary team gained more understanding and clarity around the role, their perceptions of the role became more positive. A similar trend has been found in previous studies of new roles (Miller etal, 2001: Scholes and Vaughan, 2001; RCN and SheffieldUniversity, 2004).

Perceptions of the key competencies required by the community matron to be an effective practitioner resulted in everyone either agreeing or strongly agreeing that the matron required a background in healthcare (see Figure 1). Some 92% either agreed or strongly agreed that the matron should be a nurse.

In order to ensure clarity over the level of skills and knowledge appropriate to the role, the NHS Modernisation Agency and Skills for Health provided a competency framework (2005). The study examined three of the nine key domains outlined in the competency framework: advanced clinical nursing practice; professional practice and leadership; and inter-agency and partnership working (see Table 1). Although not statistically significant, the findings support government literature that recognises that advanced clinical nursing practice is the distinguishing feature that separates the community matron role from other practitioners delivering case management (NHS Modernisation Agency and Skills for Health, 2005).

Table 1: Questions relating to the key competencies required to be an effective practitioner

	Strongly disagree	Disagree	Don't know	Agree	Strongly agree
The community matron should be a nurse		2.5% n=3	5.0% n=6	48.7% n=58	39.5% n=47
The community matron should have a background in healthcare				42% n=50	55.5% n=66
The community matron does not need to be a clinician	35.3% n=42	46.2% n=55	7.6% n=9	6.7% n=8	0.8% n=1
The community matron does not need community experience	26.1% n=31	56.3% n=67	5.0% n=6	8.4% n=10	1.7% n=2
The community matron role requires a practitioner with advanced clinical skills	1.7% n=2	5.0% n=6	5.9% n=7	43.7% n=52	40.3% n=48
The community matron role requires a practitioner with recognised leadership skills	1.7% n=2	10.1% n=12	9.2% n=11	54.6%, n=65	21.8%, n=26
All community matrons, nationally, should have the same level of knowledge and skills		17.6% n=21	10.9% n=13	46.2% n=55	21.8% n=26

Research suggests that few members of multidisciplinary teams have a clear understanding of the nature of each others' roles and responsibilities (Gerrish, 1999; Edmonstone et al, 2003). However, our findings confirm that most professionals surveyed are familiar with the community matron role. As joint and integrated working appears to be key to improving understanding (Eve and Gerrish, 2001) and lack of a structured framework for communication can result in poor integration between teams (Baileff, 2000; Edmonstone et al, 2003) it appears that early integration between the matron, community nursing and practice teams has resulted in a clearer understanding and appreciation of the role.

The role of the community matron within the multidisciplinary team

Blurred boundaries that are unclear and overlaps between roles have been identified as a potential source of conflict if not managed correctly (Woodend, 2006). Recent articles have highlighted concerns over role overlap with other healthcare professionals (Bird and Morris, 2006).

Table 2: Questions relating to perceptions about complementing existing professional roles within the multidisciplinary team

Results from earlier studies recognise that greater effectiveness is achieved in multidisciplinary teams who already work together (Scholes and Vaughan, 2002; Cummins et al, 2003; RCN and SheffieldUniversity, 2004). When considering where the community matron would be best placed, a statistical difference was found between professional roles in responding to the statment that the matron should be placed within the community nursing team (p=0.02) with 65.1% (n=21) of district nursing sisters agreeing the matron should be part of that team compared with 14% of practice managers and 35% of GPs. However, a statistically significant relationship was also found between professional roles (p = 0.018) and reponses to question of whether the matron should be placed within the practice team. In particular 68.6% (n=24) of GPs either agreed or strongly agreed compared with 33% of practice managers and 17% of district nursing sisters.

Within Durham Dales, the community matrons have been placed within a completely new team, in addition to but not as part of existing teams. This has been highlighted as a major cause of poor acceptance and service design (RCN and SheffieldUniversity, 2004). Results showed different professionals disagreed over whether community matrons should be placed in a separate long-term conditions team (p=0.016). In particular, GPs either disagreed or strongly disagreed with the statement.

Overall, half of the healthcare professionals undertaking the survey viewed the community matron role as complementing their existing role (see Figures 2 and 3 below).

Community matron aims and responsibilities

Identified key aims and responsibilities of the community matron role were: to provide support and advice to patients and their families about long- term conditions (81.6%), to improve quality of life (94.1%), as well as to reduce unplanned admissions (90.8%).

Regarding perceptions from the multidisciplinary team on whether the introduction of the community matron role had had an impact on patients living with long- term conditions in the PCT (see Figure 4 below), 37.8% felt they did not know. However, eight respondents had further clarified this by commenting that they felt it was too early to assess if there had been an impact as the role was still in its developmental stages. A statistical significance was identified between professional role (p = 0.008) and GPs, practice managers and nurse practitioners made up the respondents who either agreed or strongly agreed with the statement.

Conclusion

To conclude, the study did achieve its overall aim of obtaining the early perceptions and views on the emerging role of the community matron within the multidisciplinary team. It achieved its objectives of ascertaining the key competencies and responsibilities required in order to be an efficient, effective practitioner and obtaining views on the bio psychosocial factors that would best measure the impact of the community matron role. It did not identify any one particular area where there was lack of clarity around the role. In fact the study showed that the majority of members of the multidisciplinary team are familiar with the function and tasks of the community matron.

The role of the community matron is a new initiative and was introduced in response to results from several pilot studies that claimed huge cost savings through reduction in unplanned emergency admissions and inpatient bed days (National Primary and Care Trust Development Programme, 2004). Initially there was no guidance from the government on the role of community matron (DH, 2004a) and as such, the community matrons employed within Durham Dales PCT received no clear direction on role development. Supporting documents that attempted to improve clarity around the role of case management and that of the community matron did not appear until the matrons had been in post within the PCT for almost a year (DH, 2005a; DH, 2005b).

The results of the study support the research given in the literature review around the role of the community matron, however they do not necessarily add any depth to the current body of knowledge. The project did highlight some significant differences between localities that will need to be addressed by each matron carrying out further research to produce a more true reflection of the role perception in their own area.

Overall, information obtained from the survey suggests that, despite the role of community matron being in its early developmental stages within Durham Dales PCT, the majority of respondents are familiar with the actual role of the community matron as recommended in the competency framework (DH, 2006b), and their perceptions had not changed from when the role was initially introduced. Those who were unclear about the role and whose perception had changed stated that as the role began to evolve, understanding and clarity around the role changed views positively.

As lack of planning and evaluation have been seen to contribute to role ambiguity (Cummins et al, 2003), the results of the survey would suggest that the initial clarification and role definition carried out by the community matrons has been pivotal to its successful introduction and reduction in role conflict. There were a small minority of respondents who felt their perception had changed negatively, in particular some of the GPs in the rural areas of the locality who felt that their patients would benefit from their own community nursing teams having the appropriate skills to provide case management for those with complex needs. A statistically significant majority of community nursing sisters agreed that the matron should be part of the community nursing team, but most GPs agreed that the matrons should be part of the practice team, and most respondents in all professional roles agreed they should not be a separate team as is currently the case.

Results suggested that most respondents agreed that the role complemented their existing role, however, several members of the community nursing teams, in particular district nursing sisters from the urban localities, strongly disagreed with the statement, which is now being addressed by joint working.

Finally, over half of the respondents either disagreed or strongly disagreed that the community matron role had not had an impact on patients living in Durham Dales. Of those who perceived the role had no impact most acknowledged that as the role begins to develop and flourish, the more valuable they perceive the role to be. Almost a third of respondents added comments that recommended a need to improve role integration within existing teams, provide formal settings for feedback around patients on the matrons' caseload, and reduction in role duplication, in particular with district nursing teams. A small minority raised issues and concerns over the cost of introducing a new role in community nursing when existing nursing teams were under-resourced, and further clarified this by suggesting the skilling-up of district nursing teams as an alternative.

To summarise, there has been much criticism about the role, in particular research which suggests the promising results shown by early pilot sites have not been replicated nationally (Health Service Journal, 2004; King's Fund, 2005; DH, 2004b). Despite this the government is clear that community matrons using advanced clinical nursing care and case management are the key to providing high-quality care for people with chronic disease (DH, 2006a). In Durham Dales the evidence surrounding this new emerging role is, on the whole, very positive. After only a short time since its introduction, initial controversy seems to be subsiding as healthcare professionals begin to see the benefits of the role and how it can truly complement current existing services to provide more holistic patient-centred care. The new community matron role, despite some areas of concern, is gaining credibility and support as an autonomous practitioner which, barely one year after its introduction, is over and above what was expected by team members.

Demonstrating an efficient effective service which is developing in line with organisational changes is paramount. Obtaining early perceptions of the community matron role enabled the team to highlight potential problem areas, address issues at the early stages of role development and move this role forward into the future.

Recommendations

• A further research project over the next six months carried out by individual matrons, both quantitative and qualitative, that identifies differing needs and working practices between localities within the PCT and how this impacts on service provision for long-term conditions;
• Further research obtaining views on the service from patients, carers and their families, in particular exploring the social care and health aspect;
• Increase the visibility of community matrons by setting up formal communication links between all members of the multidisciplinary team and thus enhance integration by:
• Regular attendance at locality and team meetings;
• Regular clinical meetings with community nursing staff for feedback and discussion of patients on community matron caseload, reducing role duplication;
• Improving integration between matrons and nursing teams especially in urban localities by looking at joint initiatives such as supportive case management;
• Greater involvement of practice teams by including practice nurses and nurse practitioners in providing peer support and educational training programmes;
• In the rural areas of the locality identify individuals within district nursing teams to undergo clinical skills training as potential case managers;
• Identify GPs and nurse practitioners who will act as mentors for nursing staff wishing to further develop their clinical skills;
• Look at new ways of working, in particular, considerations as to where the community matrons and the LTC team will best be placed (such as community nursing teams and practice teams);
• Liaise with the IT department to develop further the current evaluation framework to include ways of measuring three of the four factors highlighted by the survey which are not at present measured;
• Repeat the research in a year's time to gain a clearer understanding of how the role has moved forward.

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