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Discussion

Educating community nurses

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With the drive towards more home-based care, it is vital that the education of community nurses is developed. But the form education should take is up for debate

 

In this article…

  •  How district nurse education has developed
  •  How education for community nurses could look in the future
  • Outcomes required to protect patients who are in the care of community nursing teams

  

Authors

Rosemary Cook CBE is director, The Queen’s Nursing Institute; Heather Bain is course leader community health, Robert Gordon University, and chair of the Association of District Nurse Educators; Anne Smith is Queen’s Nurse, Honorary Fellow, University of Reading.

 

Abstract

Cook R et al (2011) Educating community nurses. Nursing Times; 107: 38, early online publication.

With the combination of a growing older population, a rising number of people living alone with long-term conditions and the drive to move care into the community, it is essential that the education of the community nursing workforce is developed. This article examines the potential shape of education for community nurses in the future.

Keywords: Community nurses, Education, Specialist practitioner

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article

 

5 key points

  • By 2017, there will be more than 12 million people over the age of 65 in the UK; the number of people in England alone living with at least one long-term condition is set to rise to 18 million
  • UK health policies aim to move as much care as possible out of hospitals and into the community
  • For patients to receive effective care outside of hospitals, it is essential the education, skills and knowledge of the community nursing workforce is developed
  • The future of the specialist practitioner qualification for community pathways is under scrutiny by the Nursing and midwifery Council
  • District nurse team leaders need to combine the authority and leadership of ward sisters with the autonomy and safeguarding responsibility of health visitor

 

For those who believe nursing people at home is a specialist skill, there is some good news. Following years of decline in the number of courses leading to the specialist practitioner qualification (SPQ) in nursing in the home, a 30% drop in the numbers of qualified district nurses in the workforce (NHS Information Centre, 2011) and the closure of entire university departments that used to teach it, this policy is now being reversed in some areas (Box 1). It appears the SPQ’s focus on leadership and a strategic understanding of how communities work is being recognised as an essential part of team leaders’ preparation.

Box 1. Changing education commissions

The district nursing specialist practitioner qualification (DNSPQ) course at one university was well established and had been running successfully over many years. Regular review, and collaboration with local sponsors or employers, ensured the course was meeting not only the Nursing and Midwifery Council’s standards for specialist practitioner qualifications, but also the needs of the different local sponsors.

Three years ago, reflective of the national picture, local employers felt that, to meet the needs of changing practice, it would be better for community practitioners to take specific CPD modules – for example, non-medical prescribing and differential diagnosis – and so stopped sponsoring the DNSPQ course. However, over time, it became apparent that community practitioners in Band 6 roles without the qualification did not have the necessary knowledge, skills and competence to undertake the strategic leadership required in this role.

The strategic health authority has now ring-fenced money for the DNSPQ (and the community children’s nursing specialist practitioner qualification) for students’ fees, education fees for new practice teachers, and backfill for students. This significant support is seen as a positive development and recruitment is now under way for the DNSPQ.

 

District nurse education

The development of district nurse education is shown in Box 2.

Box 2: History of district nurse education

District nursing began in the mid-nineteenth century when the Victorian philanthropist William Rathbone employed a nurse to look after the sick poor (Audit Commission, 1999).  His work along with that of Florence Nightingale established the foundations of the district nursing service.

Liverpool Infirmary provided the first training courses for district nurses in 1863 (Baly et al, 1987). By the 1870s it was clear better training was needed to address the skill and competence required to work in the community. The Queen Victoria Jubilee Institute for Nurses was established and granted a Royal Charter in 1889 supported by the Queen’s Jubilee Fund; these nurses became known as Queen’s Nurses (Baly et al, 1987). The Institute set standards for DN training to be delivered across the four countries of the UK by different district nurse associations.

Throughout the years that followed, various changes were made to the training of district nurses, and in 1981 a mandatory training was introduced before a nurse could use the term “district nurse” in the NHS. In 1994, the Community Specialist Practitioner Qualification was introduced (UKCC, 1994) and in 2001 the UKCC published Standards for Specialist Education and Practice which Institutes of Higher Education had to incorporate within the degree programmes (UKCC, 2001). These standards identified eight community pathways with district nursing called “nursing in the home” as one of them.

 

The future of the SPQ (for all eight community pathways) is under scrutiny by the Nursing and Midwifery Council. District nurse educators are clear the current standards for their pathway, last reviewed in 2001, need revising to meet the needs of contemporary community nursing. Some employers and education commissioners are dissatisfied with the current arrangements. There is also a reluctance to commit education funds to courses that may not entirely meet service needs – hence the recent trend to commission individual modules and ad hoc courses in place of the SPQ for community nurses.

Meanwhile, new roles have reconfigured the community nursing workforce. In England, one important development was the implementation of community matrons, whose remit is to case manage patients with long-term conditions (Department of Health, 2005). Their focus is to manage the care of those with complex needs in the community to prevent hospital admissions. Community matrons are required to be advanced nurse practitioners who are also non-medical prescribers. It is also preferred – although not essential – that they have community nursing experience. Most are attached to GP practices and their caseload is identified from the practice population.

The role was developed from a model used in the US known as Evercare, in which nurses were employed to case manage patients known as “high-intensity users” of the healthcare system (United Health Europe, 2005). However, there was some criticism of how this initiative was introduced in England as the Department of Health instructed primary care trusts to implement the role, setting targets for recruitment with little consideration for the broader issues.

Clearly, the NHS operates in a different way from the US healthcare system in which the Evercare model was developed. One barrier to the success of this innovation was that practitioners were unsure of the requirements of the role, and other professionals with whom they were to liaise were equally confused. However, evaluative research has identified that most multidisciplinary team members who have worked with community matrons have been positive about the outcomes achieved (Chapman et al, 2009). Patients who have experienced care from a community matron have also enjoyed the benefits of their support.

Having set targets for the number of community matrons, the government ring-fenced money for their education and adopted the idea of using a variety of modules to upskill them. Unlike the SPQ qualification, there is no specific national educational framework or award for community matrons and the only direction available concerning the role was published by the DH. This listed a rather generic set of responsibilities:

  • Identify suitable patients for case management and stratify risk;
  • Carry out comprehensive assessment of patient and carer needs;
  • Develop a personalised care plan;
  • Proactively support patients in community;
  • Review care plans and changing needs;
  • Manage the patient journey proactively across organisations;
  • Be aware of patient situations, as primary coordinator of care;
  • Call on expertise and skills of other professionals to execute the care plan (DH, 2006).

In some areas, the community matrons’ caseloads conflicts with those of district nurses. As a result, the community matron role has been charged with contributing to the decline of district nursing – partly because of the different educational approach and because experienced district nurses were drawn into the role, seeing it as career development (Lillyman et al, 2009).

So what is the future of education for the community? How should we prepare for the “carequake” of demand, the new configurations of services, and the new roles being adopted in the community?

The new context for care

By 2017, there will be 23% more people aged over 65 in the UK – more than 12 million (Office for National Statistics, 2011). With older age comes a higher likelihood of ill health and frailty. There are also more than 15 million people in England alone who are living with at least one long-term condition such as diabetes or heart disease – this is set to rise to 18 million (DH, 2010a).

Caring for the population in a hospital-based system is acknowledged to be unaffordable. Although different political stances provide different positions on how to develop health services, each of the countries in the UK has a variety of health policies in place that aim to move as much care as possible out of hospitals and into the community – to patients’ homes and community settings (Department of Health, Social Services and Public Safety, 2011; DH, 2010b; Scottish Government, 2007; Welsh Assembly Government, 2005).If these policies are to succeed and patients are to receive expert, safe and effective care outside of hospitals, it is essential the education, skills and knowledge of the community nursing workforce is maintained and developed accordingly.

It is already apparent that care in the home has changed radically in recent years (Queen’s Nursing Institute, 2009). Advances in day surgery and reductions in length of hospital stays have made it easier to manage conditions at home, while technology has changed the nature of the patient–nurse interaction and the technical skills required of nurses. Yet, however amazing the machinery, specialist knowledge and skills remain
essential to patient safety and effective treatment.

District nurse educators debate

The Association of District Nurse Educators (ADNE) brings together those who design and teach the SPQ for nursing in the home in UK universities. It recently considered whether a revised SPQ was the way forward to ensure future community nurses could meet the challenges of providing care in the home (Smith, 2010) (Box 3).

Box 3. The Association of District Nurse Educators

The Association of District Nurse Educators (ADNE) is committed to raising the profile of district nursing. Its purpose is the educational preparation and support of district nurses as well as other health professionals working in primary and community care across the UK. ADNE members are qualified district nurses, with extensive knowledge and experience of university education.

The ADNE website (www.adne.co.uk)is a resource for information about district nursing and aims to increase awareness of the educational needs of primary care nurses. It also provides a forum for members to share ideas and research, and:

  • Act as a pressure group, lobbying for changes that will enhance the health of people in the country, through educational networks;
  • Debate and respond, as a group of professionals, to issues of national preferred policy;
  • Critically appraise current developments in district nursing to disseminate good practice;
  • Share and develop educational and research expertise to further the principles and practice of district nursing;
  • Encourage and support the professional growth and development of individuals.

The SPQ revision debate

“My concern is the pre-registration standards are not specific enough in relation to community nursing. This willallow for variation across the country so we do not have a baseline at the point of registration. However, I haveconcerns that [CPD modules] are used as a cheap alternative [to the SPQ] by employers – generally they are theoretical in nature and are not assessed in practice by a recognised practice teacher.”

“We could broaden the definition post-registration within the specialisms to ‘higher level practice’ rather than‘advanced’ as, although some will be demonstrating advanced practice qualities, others most definitely will not be at that level on recording the specialist qualification.”

“Leadership must play a far greater role than it currently does. With GP commissioning around the corner we need to be educating people who are going to be able to stand up to GPs… there is the danger of district nurses becoming the doctor’s handmaiden again.”

“The issue of district nurses programmes being a registered/recorded qualification has so many ifs and butsattached to it… we need to say the award warrants NMC recognition as a specialism in its own right, at leastequal to and alongside that of the Specialist Community Public Health Nurse programmes.”

Overall, ADNE members who participated in this debate agreed the following outcomes were essential for the protection of all patients in the care of community nursing teams:

  • Retention of a recordable qualification (or similar) for qualified district nurses;
  • Updated standards that reflect the current role of district nurses with acknowledgement of their safeguarding role;
  • A set of competencies that reflect skills required by leaders in community nursing – higher levels of judgement, discretion and decision-making; working with diverse communities; public health and community practitioner nurse prescribing competencies;
  • Retention of the standard requiring practice teachers/sign-off mentors to assess the practice elements of district nurse courses;
  • Avoidance of the SPQ course becoming a “random” series of modules.
  • Other key outcomes included:
  • The qualitative difference in outcomes between the apprenticeship model of training with local variation and purpose-designed education with common standards;
  • The parallel between the importance of health visitors for safeguarding vulnerable children and of district nurses for safeguarding vulnerable adults;
  • The parallel between the expectations and role of ward sisters, and that of team leaders in the community.

In short, district nurse team leaders need to combine the authority and leadership of ward sisters with the autonomy and safeguarding responsibility of health visitors; their preparation and recognition must reflect this.

Conclusion

Given the new context of care and the focus of government policy, the specialist preparation of nurses to work in people’s homes is the most important issue in professional education. In spite of the current financial climate, the ADNE debate confirms this is not the time to randomise the teaching of essential community skills, but rather the crucial moment to set new standards for this area protect patients and meet service delivery needs.

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Readers' comments (1)

  • Adam Roxby

    I'm still undecided as to which area of nursing I would like to go into but having access to well articulated essays such as this will certainly make the choice an informed one.

    Many thanks

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