Patients were found to have positive views of community matron services, valuing their support and reliability, and the reduction in hospital admissions
Mandy Bowler, MSc, BSc, RGN, DMS, OND, JP, is business manager/senior nurse in planned care, NHS South of Tyne and Wear.
Bowler, M. (2009) Exploring patients’ experiences of a community matron service using storybooks. Nursing Times; 105: 24, 19-21.
Background: Several Department of Health policy documents outline a vision for services to be designed around patients. The community matron service was introduced across NHS South of Tyne and Wear PCTs in 2005 and has developed over the last four years to offer a seven-day service to patients, delivered by 52 community matrons.
Method: A project in 2008 to gather patients’ views of the service led to the development of service ‘storybooks’. These are a rich source of data, captured through in-depth, semi-structured interviews.
Results and conclusion: The data captured shows the community matron service is a well regarded and beneficial service. The most important factors for patients included: an assurance of the service being there; reliable/supportive staff; effective communication skills; and matron availability. The storybooks reveal high levels of patient satisfaction and the importance the service gives to patient involvement.
Key words: Community matron, Patient satisfaction, Patient outcomes, Education and support
- This article has been double-blind peer-reviewed
- This research shows that patients are extremely satisfied with the community matron service.
- The patient storybooks reveal those aspects of the service that patients particularly value, such as avoiding hospital admission, support for self-care and the importance of patient-centred care.
- The data also revealed specific examples of how the community matrons had had a positive impact on patients’ lives.
The community matron role was highlighted in The NHS Plan (Department of Health, 2000) and in several subsequent documents on meeting the needs of patients with long-term conditions (DH, 2009; DH, 2006a; DH, 2005a).
While the role’s initial focus was to provide proactive case-management for patients considered high-intensity service users, the complexities of this client group, who may have several long-term conditions, meant the role was initially restricted to a more reactive service.
Successful management of this type of patient requires skills in managing several specific long-term conditions, mental health and end-of-life care.
The national drivers for community matron services are to improve outcomes for people with long-term conditions and to offer personalised care plans with the aim of reducing emergency bed-days.
The community matron role was first implemented in NHS South of Tyne and Wear, which incorporates Gateshead PCT, South Tyneside PCT and Sunderland Teaching PCT, in 2005. The initial model has been developed and a seven-day service is now offered during the core hours of 8.30am–5.30pm, including bank holidays.
Partnership working across acute, primary and social care has been slow but steady. Many patients are now able to remain in their own homes successfully with the continued support and supervision of a community matron. The success of the service has been measured locally using patient satisfaction and caseload audits.
Our Health, Our Care, Our Say (DH, 2006b) stipulated that it is a fundamental duty of (provider) services to systematically and rigorously find out what people want and need from their services. This national agenda of ensuring that services have a truly patient-focused approach is a key driver for reform locally.
As we were keen to understand what makes the community matron team important to patients and how we could improve on the effectiveness and quality of this service in the future, a project was carried out to gain a more in-depth overview of patients’ experiences of the service.
In 2008, 124 patients contributed to the development of three patient storybooks, one for each PCT area, which offered a more detailed, in-depth view of the community matron service from patients’ perspective.
The aim of developing storybooks to obtain patient feedback, instead of using the usual method of satisfaction questionnaires, was to try to build on past surveys with richer and more meaningful patient narrative.
The NHS Plan (DH, 2000) set out a vision for services to be designed around patients, which are high-quality, fast, convenient and use modern methods to provide care where and when it is needed.
Such services need to be designed around patients but also be responsive to them, offering choices and involving them in decision-making and planning.
Creating a Patient-Led NHS (DH, 2005b) stipulated that the NHS should move away from a service that does things to and for its patients to one that is patient-led and where the service works with patients to support them with their health needs.
Our Health, Our Care, Our Say (DH, 2006b) expanded on this, and clearly set out that NHS organisations must ensure that local people (service users) play a full part in the planning, design and delivery of services.
This national agenda is a key driver for reform to ensure that our local services have a truly patient-focused approach.
It is therefore essential that we create opportunities for patients and service users at all levels to participate in meaningful dialogue about care delivery so they can help influence and improve local services.
To ensure that all 52 community matrons were included in the project, each was asked to identify a number of patients on their caseload who would be suitable to participate in a semi-structured interview.
This could last up to an hour and patients were invited by letter to take part. Interviews took place in patients’ own home and were facilitated by a member of the clinical modernisation team, who guided them through 17 questions on the service and its delivery. An open question at the end enabled service users to express themselves freely.
In total, 124 patients participated, with at least two from each community matron’s caseload. Every patient was assured of anonymity and told they did not have to inform the community matron of the interviewer’s visit and purpose.
To ensure validity, the discussion was documented and then read aloud to participants, who were asked to confirm they recognised the narratives as a true reflection of what they had said.
The information collected is presented in two parts. First, a quantitative evaluation places emphasis on meaning and interpretation of the data (Polgar and Thomas, 2000) and, second, qualitative evaluation recognises complexities and richness of human experiences (Mason, 1996).
Each of the three storybooks (Gateshead, South Tyneside and Sunderland) had many similarities, which can be attributed to consistent practice being implemented across the NHS South of Tyne and Wear community matron services. However, there are some subtle differences that reflect the individual nature of each community matron team. For the purposes of this article, the results will be presented collectively.
Of the 124 patient participants, 42% were men and 58% women. All apart from one participant were over 50 years, with 24% over 70 and 19% over 80.
The most important factors for patients included: an assurance of the service being there (37%); reliable/supportive staff (17%); effective communication skills (11%); and matron availability (8%).
Responses indicated that service users placed great emphasis on forming relationships with staff and avoiding hospital admission to help support them at home. For patient quotes, see Box 1.
Box 1. Patient comments on the community matron service
- ‘I was getting myself depressed but, with the matrons, you feel assured you’ve got someone to come out when you need them.’
- ‘When the hospital tried to organise things nothing happened but, with the matrons, if they say something will be done, it gets done.’
- ‘I don’t like being in hospital with all their germs, I like being home with my family and the matrons help me do that.’
- ‘They are always there if you need them. Confident that someone’s there for you if you need them.’
Referral and access
Most patients could remember how they had been referred to the community matron service. Half of all referrals came from general practice. This may have been direct patient referral or by identifying appropriate patients using the King’s Fund Patients at Risk of Rehospitalisation (PARR) tool.
One-third of patients (34%) had never had to call the community matron. Of those who had, all but one confirmed that access was easy, straightforward and reliable.
The level of intervention needed by patients calling the service varied; it may have been advice and reassurance over the phone, a home visit and assessment or a referral to some other member of the healthcare team.
Patients quotes included:
‘I can phone her and never had any bother.’
‘Very easy. You’ve always got backup if your matron is on holiday. They let you know that they are going on holiday and make sure you have backup.’
When patients were asked whether community matrons do anything differently from other professionals or agencies, the most common answers seemed to relate to how satisfied they were with the amount of time afforded to them by the community matron.
The biggest comparisons were made with GP services and hospital wards, where patients reported that much less time was available.
Patient quotes included:
‘They’ve got more time for you. When you go to the GP and hospital, people are always rushing. Matrons don’t have a “set time and you’re out” – they take as long as required.’
‘She visits me regularly and examines me thoroughly when I’m poorly – more than the GP.’
‘When the matrons come, you feel that they are exclusively for you and the clock is not important.’
Overwhelmingly, patients identified that the community matron service had made a difference to them personally – 44% said they were spending less time in hospital, 24% were feeling more confident and 16% said their health or social circumstances had improved.
Patient quotes included:
‘I’ve never had to call the GP and go to hospital. Haven’t been to hospital since seeing the matron.’
‘I was in hospital five times in one year, matrons sorted out medication and I haven’t been in since three years ago.’
’Kept me out of hospital for 12 months which was brilliant.’
‘I was in and out of hospital like a yo-yo and now that’s stopped.’
’Spent less time in hospital. Before the matrons came I was in and out of hospital for two years – 28 times! Haven’t been since.’
Patients’ responses, when asked about the professionalism and attitudes of the community matrons, were 100% positive. All were thought to be respectful, professional and caring. See Box 2 for patient quotes on this.
Box 2. Patient comments on community matrons’ caring attitude
- ‘You feel like they are genuine with you.’
- ’They are far more friendlier, where with the hospitals you’re just a number.’
- ‘When you go to the GP you never see the same doctor twice and they don’t talk to you, they talk to the computer. With the matrons, it’s so personal, they know who you are and you’re not waiting in line with music playing.’
- ’Absolutely lovely, makes you feel that you’re really important and not just another name in her diary.’
- ’Matrons are very professional but share things with you that make you feel like a friend. I trust them implicitly.’
- ’You think the way she talks to you, you are her favourite, but you realise that she’s like that to everyone. When she comes she’s just so helpful. She’s very approachable.’
The extra time matrons afford to their patients may play its part in influencing patients’ perceptions of their skills; 17% recognised the community matron used easy-to-understand language when communicating which helped to explain things better and put them at ease.
Patient quotes included:
‘When you’re at the hospital, it’s all technical words but the matrons break things down into simple terms.’
‘Much better than the GP at explaining things.’
Almost three-quarters (73%) of patients strongly believed they were involved in their own care, that is, they had more options open to them and their opinions were genuinely sought.
Patient quotes included:
‘She [the matron] tells you things and lets you make up your mind.’
‘Everything she does she discusses with you first.’
‘With her taking her time, she gets you involved in decisions being made. She’s not geared just at your health but your entire lifestyle.’
‘She teaches you how to look out for you getting poorly beforehand so that you know to get help.’
The case-manager role appears to be making a difference to patients’ lives as they indicated that, because of the community matron’s involvement, they were managing much more independently. See Box 3 for comments on this.
Box 3. Patient comments on self-care and independence
- ‘I self-treat myself a lot more because now I have a nebuliser.’
- ‘Matron’s organised carers to come in and loads of equipment which has transformed life around the home.’
- ’It’s a lot easier to get around the house due to all the equipment he’s got me.’
- ‘Organised a stair lift, I was getting nowhere with it before her.’
- ‘I went on holiday and she arranged oxygen at my holiday destination.’
- ‘Of all the improvements that have happened in the NHS this is the most important service to come out of it. When you see the matron, they look at everything about you and link with everyone else in the NHS so you get everything you possibly need.’
When asked about the appearance and infection-control measures that community matrons took while in their homes, all patients said the uniforms gave a professional, clean and smart appearance, 57% confirmed they always washed their hands during a visit and 47% said they used hand gel or patient wipes.
So what did patients class as good about the service? The top answers focused on assurances of the service being there, the availability and reliability of the team, the avoidance of hospital admission and the effective skills of the community matrons themselves. See Box 4 for patient quotes.
Box 4. Patient comments on positive aspects of the service
- ‘When they ring and I hear them on the phone, I feel assured. I’ve never been happier as a patient.’
- ‘I feel more confident and it’s made a huge difference.’
- ‘Professional staff who know what they are doing.’
- ‘If I was a multimillionaire, I couldn’t buy the service. When she comes round, she doesn’t just talk about the medical stuff but social things which makes all the difference.’
- ‘I think they are marvellous because they do try to help as much as they can.’
- ‘It’s been a blessing since the matron started visiting me. I can honestly say it’s the best thing that’s happened to us.’
- ‘We like the matron, we clicked with her straight away.’
- ‘Her advice has helped me. My life is easier because of everything she’s organised. I’ve got more peace of mind.’
Only three patients out of the 124 interviewed highlighted an aspect of their community matron service that was not so good, which equates to a 97% satisfaction rate.
The negative patient comments were as follows: ‘First, matron only checked me once in two years’ and ‘If I have to wait more than half an hour [after calling community matrons], I’d be inclined to go to the walk-in centre.’
When asked what they would recommend to improve the service, service users came up with few suggestions. A few suggested more visiting, advertising the service and offering it to all people aged over 80 years.
Although patients of community matron services have a variable mix of long-term conditions, they often have one thing in common – the view that in the past other professionals have not always had the time to devote to their individual needs.
In contrast, the community matron’s role is one that provides close attention to the individual until case-management techniques and self-management plans can be fully implemented.
What is evident from the patient storybooks is how the South of Tyne and Wear community matron team appears to be extremely patient-centred in its approaches to health care delivery.
The team’s work also appears to be contributing towards patients’ reduced use of hospital and GP services.
While we can be assured that service users are having a good experience, we still need to ensure the service is constantly reviewed, taking into consideration our patients’ thoughts, views and opinions.
Although it is not possible to gather the richness of information needed for the full storybooks each year, due to the labour intensiveness of the interviews, annual patient satisfaction surveys will be continued and patient views sought during all service review or changes.
Following these first sets of storybooks, some comments have encouraged us to revisit and update our service leaflets and actively promote the service across primary and acute care to ensure that patients who may benefit from the service are referred in a more timely manner.
The most prominent features that have emerged from the storybook data are the levels of satisfaction that patients have with the service and the importance given to patient involvement and patient-centred care.
The data also confirms that the service helps reduce the number of hospital episodes through supporting patients to manage their conditions as independently as possible at home.
The three community matron teams also compare favourably against other services such as GP practices and hospital wards. This is a credit to each of the nurse-led community matron teams who work across NHS South of Tyne and Wear.
Department of Health (2009) Supporting People with Long Term Conditions: Commissioning PersonalisedCare Planning – A Guide for Commissioners. London: DH.
Department of Health (2006a)Caring for People with Long Term Conditions: an Education Framework for Community Matrons and Case Managers. London: DH.
Department of Health (2006b) Our Health, Our Care, Our Say: A New Direction for Community Services. London: DH.
Department of Health (2005a) Supporting people with Long Term Conditions: An NHS and Social Care Modelto Support Local innovation and Integration. London: DH.
Department of Health (2005b) Creating a Patient-Led NHS. Delivering the NHS Improvement Plan. London: DH.
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: DH.
Mason, J. (1996) Qualitative Researching. London: Sage.
Polgar, S., Thomas, S.A. (2000) Introduction to Research in the Health Sciences. London: Churchill Livingstone.