hr. J. Nurs. Stud., Vol. 29, No. 1, PP. 37-41, Printed in Great Britain.
1992.
0
0020.7489192 IS.00 + 0.00 1992 Pergarnon Press plc
The role of the specialist in community nursing: perceptions of specialist and district nurses F. H. HASTE,
Ph.D.
HEA Primary Health Care Unit, The Churchill Hospital, Headington, Oxford OX3 7LJ, U.K.
L. D. MACDONALD,
Ph.D.*
Department of Public Health Sciences, St George’s Hospital Medical School, Cranmer Terrace, London S WI 7 ORE, U.K.
investigated the management of specialist nurses and how district and specialist nurses perceived themselves and each other, in terms of responsibility, autonomy, skills and training, communication, role conflicts and job satisfaction. All locality and neighbourhood nurse managers, all specialist nurses, and all district and community staff nurses in one Health Authority were interviewed and surveyed. There was little disagreement about the role of the specialist nurse. District nurses were largely positive about specialist nurses, but the area of “hands-on” care was difficult for both groups of nurses. Communication between district and specialist nurses needed to be improved. Both specialist nurses and their managers believed that specialists were inappropriately managed. Abstract-We
Introduction
The concept of the specialist nurse originated in North America and gained ground in Britain in the 1970s. Casteldine (1982) attributes the rapid increase in the number and types of specialist nurses to increased public demand for services, expansion of knowledge and skills *Author to whom correspondence
should be addressed. 37
38
F. H. HASTE
AND
L. D. MACDONALD
in medicine and nursing and the interest of nurses in a more varied career structure in clinical nursing. Specialist nurse posts were instituted in various parts of the country, but because developments were on a localized basis, there was no official definition of the specialist role which fitted easily into the existing nursing hierarchy, nor were there agreed requirements of expertise, experience or qualification (Baker and Kramer, 1983; Holt, 1984; Hart et al., 1987). Casteldine (1983) in Britain, identified 11 de facto elements: being trained in the speciality, having role independence and personal accountability, being an expert, a change agent, educator, doing research, publishing, coordination and liaison, and direct care. Aradine and Deynes (1972), in North America, had earlier defined a similar list of elements. Boucher and Bruce (1972) had defined the role as practitioner, educator, researcher and change agent, while Storr (1988) added to these the elements of consultant and staff advocate. Others have refined or modified the lists of role elements (Sparacino, 1986; Tavistano et al., 1986) with essentially the same definitions. It may be that lack of clarity about the role of specialists has affected their acceptance by other professional groups. Several works have emphasized that other nurses, in particular district nurses, were fearful that their roles were being eroded and their jobs de-skilled (Canham and Murray, 1989; Kindlen, 1987; Keller, 1973). Several researchers (Harrell and McCulloch, 1986; Wade and Moyer, 1989) have observed that there is a need for more research in Britain about the effectiveness of specialist nurses, in terms of their actual impact on patient care. Some studies have attempted to evaluate the effectiveness of specialist nurses, particularly in the areas of diabetic care (Moyer, 1987; Moyer, 1989), stoma care (MacDonald and Anderson, 1985; Wade, 1989), respiratory care (Cockcroft et al., 1987) and terminal care (Doyle, 1982; MacDonald, 1989; Parkes, 1980). But the outcome measures used, e.g. quality of life, patients dying at home, satisfaction ratings are, in the main, difficult to measure and their suitability as outcomes hard to assess. Wandsworth, a large inner city London Health Authority, decided in 1988 to appoint specialist nurses and, by the end of 1989, had three specialist HIV nurses, three nurses for the elderly, two diabetic nurses, two MacMillan nurses, two terminal care coordinators and one nurse for the physically handicapped. All worked in the community and were accountable to community nurse managers. However, by the end of 1989 there were financial constraints and an understaffed district nursing establishment which meant that the community nursing service was severely stretched. The integration of specialist nurses into the community service was acknowledged to have been neither consistent nor systematic. As a result, although a previous survey had established that district nurses were ready to accept, at the least, terminal care specialists (MacDonald and Macnair, 1986), there was potential for poor inter-staff communication, poor coordination of patient services, and for role conflicts between specialist and district nurses. It was felt that this situation might affect efficiency and effectiveness of service provision and district nurses’ job satisfaction, with consequent recruitment and turnover problems. This survey was undertaken at the request of the Unit General Manager for Continuing Care. It was designed to investigate the issues involved in management of specialists and the roles of district and specialist nurses as perceived by themselves and each other, in terms of responsibility, autonomy, skills and training, communication, role conflicts and general job satisfaction. Methods
The study population comprised all locality and neighbourhood
nurse managers in the
THE SPECIALIST
IN COMMUNITY
NURSING
39
Health Authority, all specialist nurses, and all district nurses and community staff nurses. All managers and specialist nurses were interviewed, the former with open-ended and the latter with closed-format schedules. District nurses were given a self-complete questionnaire. Both specialist and district nurses also completed a questionnaire derived from the Minnesota Nurse Satisfaction Questionnaire (MNSQ) (Ward and Fetler, 1979). This questionnaire used the same format as the MNSQ, but it was reduced from 120 to 49 questions to exclude questions that were not relevant to a community setting or were inappropriate in an English context. Some wording was changed to suit the English idiom. The original and the revised version of the MNSQ were tested for internal consistency on a group of 18 2nd year nursing students (Cronback’s alpha 0.76). The original paper had identified seven factors (or themes) using factor analysis: professional considerations, working conditions, professional preparation, pay, emotional climate, supervision and social significance. Questions from all seven factors remained in the shortened version of the questionnaire. Respondents were asked to score their answers to individual questions on a scale from 1 (very satisfied) to 4 (very dissatisfied). Answers to the questionnaire were analysed in three ways: firstly, scores of individual questions were compared between groups of nurses; secondly, scores of the questions comprising each factor were aggregated and medians of the aggregated scores for each factor were compared between groups of nurses, using a Mann-Whitney U-test; and thirdly, the proportions of each group of nurses whose scores indicated dissatisfaction (scores 3 or 4) were calculated as a percentage of total responses aggregated within each factor.
Results Nurse managers
All community nurse managers in Wandsworth were interviewed-10 neighbourhood and two locality. The majority felt that the introduction of specialist nurses had resulted in better patient care, improvement in district nurses’ knowledge and better communication between hospital and community. They also identified some resentment by district nurses that specialists, with the exception of HIV nurses, were eroding their role. Specialists were regarded as having been imposed upon rather than growing out of and extending general nursing. Although their work was seen to be worthwhile, integration of specialists into the community service was not as good as it might have been. There was lack of agreement among managers about whether specialists gave “hands-on” care, suggesting that some confusion remained about the specialist role, with potential for conflict and managerial confusion. A combined district and specialist nurse role, whereby district nurses developed their own specialities was seen by the majority of managers as the most desirable way to overcome these problems. No manager believed that the introduction of specialists had had any effect on the motivation, satisfaction or turnover of district nurses in the Health Authority. These were affected by structural factors such as chronic staff shortages, and by external factors such as the characteristics of the inner city case load, or the cost of housing in inner London. Managers felt they were not fulfilling their management role properly, some because they hardly ever saw the specialist, some because they were unsure of what management of these nurses entailed. There was confusion and lack of agreement about who actually managed individual nurses. Responses to the question, ‘Who manages specialist nurses?’ were as follows: some thought that all the nurses were managed by neighbourhood nurse managers
F. H. HASTE
40
AND
L. D. MACDONALD
(two responses), some that all were managed by locality managers (three), that neighbourhood nurse managers managed the HIV, elderly and diabetic specialists, while the locality managers managed the rest (five), that neighbourhood nurse managers managed only the HIV and diabetic specialists (one), or that neighbourhood nurse managers managed only the elderly and diabetic specialists (one). This lack of clarity suggests that accountability was poor. There was little overall enthusiasm for an increase in the number of specialist nurses in the future. Suggestions included a continence advisor, a child abuse nurse (two), mastectomy counsellor (one) and stoma care nurse (one). Three wanted fewer specialists. The majority favoured district nurses developing specializations to combine with district nursing duties. However, it was believed that specialist HIV nurses were needed because few district nurses yet had sufficient training to cope with HIV patients. Specialist and district nurses Interviews were obtained with all specialist HIV, terminal care, diabetic and elderly nurses, 12 in all. The physical handicap specialist was not interviewed. All district nurses, and all but one community staff nurse completed questionnaires, 40 altogether. (Numbers in brackets refer to number of respondents.) Role definitions. Using items from the specialists’ job descriptions and others suggested by senior nurses, a list of role elements was drawn up (Table 1). Both specialist and district Table 1. Perceptions of the role of the specialist nurse Specialist nurses (n= 12) Disagree Unsure Agree n % n Vo n % Train district nurses in speciality
11
Advise patients
12 (100) -
(92) 1
16 (40) 24 (60)
(8) -
Give hands-on care
5
(42) 7
(58) -
Be fully responsible for patients
4
(33) 8
District nurses (n = 40) Agree Disagree Unsure n % n % n Vo -**
39 (98) 1 (2) 16 (40) 21 (53)
3
(8)
9 (23) 30 (75)
1
(2)
Liaise between patient and hospital
12 (100) -
(67) -
Liaise between patient and GP
12 (100) -
-
39 (98) 33 (82)
1 (2) 7 (18)
-
(25) -
33 (82)
7 (18)
-
Liaise between district nurses and hospital Counsel patients Do research Assess needs Instruct district nurses Ensure district nurses follow instructions
9 11
(75) 3 (92)
1
(8) -
38 (95) 1 (2) 13 (33) 26 (65) 16 (40) 23 (58)
1 1 1
(2) (2) (2)
5 8
(42) 6 (67) 3
(50) (25)
4
(33) 8
(67) -
15 (38) 25 (62)
-
3
(25) 9
(75) -
7 (18) 33 (82)
-
1 1
(8) (8)
**Significant difference between perceptions of specialist nurses and district nurses (x2 = 7.5, P < 0.01).
nurses were asked if they thought each element was part of the specialist role in the Health Authority. Most specialists agreed that it was part of their role to train other nurses, advise patients and nurses, liaise between patient, hospital and GP, and to counsel patients. The majority believed that providing hands-on care, being responsible for patients overall, concentrating on research, giving instructions to district nurses and ensuring that instructions
THE SPECIALIST
IN COMMUNITY
41
NURSING
were carried out were not part of their role. The opinions of district nurses were very similar, except that they were considerably less likely to feel that training other nurses in their speciality was part of the specialist role. Fulfilment of the specialist nurse role Specialist nurses were asked about what they actually did. District nurses were also asked about hands-on care provided by the specialist. Although most specialists said their role involved training other health professionals (1 l), some (three) provided neither formal nor informal education. One spent six hours/week in formal teaching; the others offered few formal sessions. Some said they did no informal teaching (two), while others spent “about half the time” (three) or “all the time” (three) informally educating nursing staff. Most agreed that counselling patients was part of their role (11). Many estimated that half or more of their time with patients was spent in counselling (nine). Only a minority had been involved in research. Two were employed on an existing trial and three had participated in research at some time. Two specialists, both HIV nurses, said they routinely gave hands-on care, others said they would in an emergency, or when district nurses were not available (eight). This latter circumstance was observed to be becoming increasingly common as the crisis in district nurse staffing continued. Among district nurses, 40% felt that hands-on care was part of the specialist role. A small minority said that specialists routinely provided hands-on care, although more said they would in an emergency. A higher proportion of district nurses than specialists said the latter should be giving hands-on care routinely (Table 2).
Table 2. (a) Do specialist nurses provide hands-on District nurses’ views Terminal care Locality nurses nurses for the elderly
HIV nurses n
VO
Yes-routinely Yes-sometimes No Do not know Not applicable
4 10 10 3 13
(10) (25) (25) (8) (32)
2 10 26 2
(5) (25) (65) (5)
Total
40
(loo)*
40
(loo)*
n
(b) Should
Yes-routinely Yes-sometimes No Do not know Not applicable No response
13 12 7 1 7 -
(33) (30) (18) (2) (18)
Total
40
(loo)*
*Some totals
%
n
1 40
do not add up to 100 due to rounding.
(25) (43) (28) (2)
Diabetic nurses
%
n
10 22 8
(0) (25) (55) (20)
4 17 14 4 1
(10) (43) (35) (10) (2)
40
(loo)*
40
(loo)*
17
(43)
18 5
(4:) (13) 0 0
40
(loo)*
specialist nurses provide hands-on District nurses’ views 10 17 11 1
care?
5 20 13 -
(13) (50) (33)
(2)
2
(5)
(lOO)*
40
(loo)*
070
care?
42
F. H. HASTE
AND L. D. MACDONALD
Perceived effectiveness of specialist nurses Acting as a resource person was defined as a major element of the specialist role. To ascertain how effective specialists were in fulfilling this role, district nurses were asked whether having specialists had improved their knowledge. The majority said they had increased their knowledge of how to care for terminally ill (62%) and diabetic patients (80%). One-third had no option about HIV nurses due to lack of contact, but of the rest, 70% said their knowledge of HIV conditions had improved. Nurses for the elderly were thought to have reduced the numbers of inappropriate discharges (70%). Perceptions of communication between specialist and district nurses differed between the two groups. All specialists felt that communication was good or very good while 22% of district nurses said that communication was poor or very poor. However, 86% of district nurses felt that communication between hospital and district nurses had been improved, particularly by the efforts of the nurses for the elderly (86%). Two-thirds of both district and specialist nurses agreed that formal meetings between them should be increased. District nurses also wanted more meetings with specialists at patients’ homes (85%). In their liaison role, the majority of specialists felt that communication between themselves and the hospital was very good (six) or adequate (four). Liaison with GPs was less satisfactory and communication with them was seen to be poor or very poor (five), and needed to be improved (10). GPs were thought to have a very poor understanding of the specialist role and were reluctant to use these nurses (four). Usefulness of specialist nurses’ work The usefulness of specialists to others nurses and to patients was assessed by asking both district and specialist nurses to rank eight aspects of the specialist role. Rankings have been grouped as l-3 (high), 4-5 (medium), 6-8 (low) and 0 (no usefulness). Usefulness to nurses. District nurses most often ranked counselling highest, followed by advising patients and giving information/advice to nurses (Table 3). Formal teaching was given low ranking overall. There was little agreement about coordination of medical care or assessment of needs-almost equal proportions ranked these as being of high, medium and low/no usefulness. Hands-on care was most frequently ranked as of low/no usefulness. Specialist nurses ranked advice to patients (nine), coordination of care (seven) and advice to nurses (six) highest. Research and hands-on care were regarded as least useful (nine). Specialists were less likely than district nurses to rank counselling patients as useful to other nurses (half vs three-quarters). Usefulness to patient care. District nurses regarded the most useful aspects as counselling patients, advising patients and advising nurses. There was less agreement over needs assessment, coordination of care and formal teaching. Hands-on care was again most frequently ranked as of low or no usefulness. Among specialists, advice to patients (nine), needs assessment (seven) and counselling patients (six) were ranked as being of high usefulness. Hands-on care (10) and formal teaching of health professionals (six) were ranked as of low/no usefulness to patient care. Role conflict District nurses were asked several questions about whether specialists were eroding the traditional district nurse role. Depending on the speciality, 20-50% felt that specialist nurses routinely or sometimes did work that district nurses should be doing (Table 4). The majority (53%) preferred to assess the elderly themselves, an additional 5% wanting some specialist backup.
THE SPECIALIST
IN COMMUNITY
43
NURSING
Table 3. District nurses’ perception of the usefulness of aspects of the specialist role High (rank l-3)’ % n
n=40 Medium Low (rank 4-5)* (rank 6-S)* n
070
n
Not useful (rank 0)*
%
n
%
Missing n
%
(i) to district nurses Role aspects Formal teaching Needs assessment Counselling Advice to nurses Research Coordination of care Advice to patients Hands on care
7
(18)
15 31 24 7 13 21 1
(38) (78)
w
(18) (33) (68) (2)
11 I 4 10 2 11 4 7
(28) (18) (10) (5) (5) (28) (10) (18)
9 13 2 1;:
(22) (32) (5) ,::i
9 6 20
(22) (15) (50)
9 2
(22) (5)
1 1: 3
(2) ,::; (8)
:
,:;;
1 5 3 0 4 3 :
(3) (13) (8)
4 3
4 2 3
(10) (8) (5) (5) (8) (10) (5) (8)
6 6 6 5 6 5 5 6
(15) (15) (15) (13) (15) (13) (13) (15)
2 23
(ii) to patient care Formal teaching Needs assessment Counselling Advice to nurses Research Coordination of care Advice to patients Hands on care
15 12 20 19 9 14 20 2
(38) (31) (50) (48) (22) (35) (50) (5)
9 8 10 14 5 8 10 3
(22) (21) (25) (35) (13) (20) (25) (8)
9 9 :. 16 10 4 22
(22) (22) (2) (5) (40) (25) (10) (55)
(10) (8) (2) (18)
*Nurses were asked to rank each role aspect from 1 to 8 or as not useful. Ranks l-3= high, 4-5 = medium. 6-8 = low.
Table 4. Are specialist nurses doing work that district nurses should be doing? HIV nurses
Yes-regularly Yes-sometimes No Do not know Not applicable No response Total
n
070
1 12 14 4 9 0 40
(2) (30) (35) (10) (23) (100)
District nurse responses Terminal care Locality nurses nurses for the elderly n % % n 2 20 16 2 0 0 40
(5) (50) (40) (5)
(100)
6 12 19 2 0 1 40
(15) (30) (48) (5) (2) (loo)
Diabetic nurses n % 2 6 29 1 0 2 40
(5) (15) (73) (2) (5) (100)
Nearly half (45%) preferred to care for terminally ill patients, with 20% more preferring some backup. Fewer preferred to nurse HIV patients (18% with no specialist; 25% with some backup). District nurses expressed varying degrees of uncertainty about how to care for the patient groups under consideration: HIV patients, 62% uncertain, diabetic patients 529’0, and terminally ill patients 43%. All but one mentioned the need for more training in HIV and terminal care, particularly counselling skills (6Ovo) and symptom control (66%). Threequarters felt they needed more training in diabetic care and care of the elderly. Just seven district nurses (18%) had had any post-registration courses in specific aspects of care, or care of particular categories of patients.
44
F. H. HASTE
AND
L. D. MACDONALD
Positive and negative feelings All respondents were given a series of statements expressing positive or negative feelings about the role of specialist nurses. District nurses were asked whether they agreed; specialists were asked whether they thought district nurses would agree (Table 5). Table 5. Positive and negative feelings* District nurses (n = 40) Agree n
%
Disagree n
%
Specialist nurses (n = 12)
NR
DK n
%
n
%
Agree n
%
Disagree n
DK
NR n
xZPt
%
n
%
%
(8)
1
(8)
-
0.3
5
36 (90)
3 (8)
-
1
(2)
10 (83)
Resentful 15 (38)
23 (58)
-
2
(5)
9 (75)
2 (17)
1
(8)
-
4.9 0.05
Positive
27 (68)
11 (28)
1
(2)
1
(2)
5 (42)
6 (50)
1
(8)
-
1.3
NS
Annoyed
25 (63)
11 (28)
2
(5)
2
(5)
9 (75)
3 (25)
-
0
NS
Confident 32 (80)
7 (18)
1
(2)
8 (67)
4 (33)
-
0.5
NS
1
(2)
9 (75)
2 (17)
1
(8)
-
3.1
NS
2
(5)
7 (58)
4 (33)
1
(8)
-
5.2 0.05
Relieved
Anxious
18 (45)
20 (50)
Indignant
9 (23)
29 (73)
-
1
(2) -
1
NS
*Responses of district and specialist nurses to the statements “I think district nurses feel . . . about specialists”. tcomparison of district and specialist nurses for each question. Missing values excluded. NS = not significant; DK = don’t know; NR = no response.
District nurses were generally favourable about the role of specialist nurses. Most agreed with the positive statements and a majority disagreed with all but one negative statement. Most agreed that: “district nurses feel angry because they are not always informed of what specialist nurses are doing”. Specialists had a more negative view of what district nurses felt about them and felt that district nurses would be more likely to agree with the negative statements. Management of specialist nurses Specialist nurses were asked who managed them, whether their manager was appropriate, and whether they had enough contact with and support from their manager. Each group of specialists agreed about who managed them. Seven felt their manager was appropriate. Five felt they did not have enough contact with their managers and six that they did not get enough support. Job satisfaction District nurses expressed significantly more dissatisfaction than specialists, with higher dissatisfaction scores on the factors emotional climate, professional considerations, social significance, pay and professional preparation. They also tended to be more dissatisfied with working conditions (Table 6). The distribution of factor scores (Table 7) shows that district nurses were least satisfied with working conditions, pay and professional preparation.
THE SPECIALIST
IN COMMUNITY
45
NURSING
Table 6. Aggregated factor scores on nurse satisfaction questionnaire Factor (number of questions: possible range for factor)
Specialist nurses median (range) 92.5
District nurses median (range)
P
1992.
0
0020.7489192 IS.00 + 0.00 1992 Pergarnon Press plc
The role of the specialist in community nursing: perceptions of specialist and district nurses F. H. HASTE,
Ph.D.
HEA Primary Health Care Unit, The Churchill Hospital, Headington, Oxford OX3 7LJ, U.K.
L. D. MACDONALD,
Ph.D.*
Department of Public Health Sciences, St George’s Hospital Medical School, Cranmer Terrace, London S WI 7 ORE, U.K.
investigated the management of specialist nurses and how district and specialist nurses perceived themselves and each other, in terms of responsibility, autonomy, skills and training, communication, role conflicts and job satisfaction. All locality and neighbourhood nurse managers, all specialist nurses, and all district and community staff nurses in one Health Authority were interviewed and surveyed. There was little disagreement about the role of the specialist nurse. District nurses were largely positive about specialist nurses, but the area of “hands-on” care was difficult for both groups of nurses. Communication between district and specialist nurses needed to be improved. Both specialist nurses and their managers believed that specialists were inappropriately managed. Abstract-We
Introduction
The concept of the specialist nurse originated in North America and gained ground in Britain in the 1970s. Casteldine (1982) attributes the rapid increase in the number and types of specialist nurses to increased public demand for services, expansion of knowledge and skills *Author to whom correspondence
should be addressed. 37
38
F. H. HASTE
AND
L. D. MACDONALD
in medicine and nursing and the interest of nurses in a more varied career structure in clinical nursing. Specialist nurse posts were instituted in various parts of the country, but because developments were on a localized basis, there was no official definition of the specialist role which fitted easily into the existing nursing hierarchy, nor were there agreed requirements of expertise, experience or qualification (Baker and Kramer, 1983; Holt, 1984; Hart et al., 1987). Casteldine (1983) in Britain, identified 11 de facto elements: being trained in the speciality, having role independence and personal accountability, being an expert, a change agent, educator, doing research, publishing, coordination and liaison, and direct care. Aradine and Deynes (1972), in North America, had earlier defined a similar list of elements. Boucher and Bruce (1972) had defined the role as practitioner, educator, researcher and change agent, while Storr (1988) added to these the elements of consultant and staff advocate. Others have refined or modified the lists of role elements (Sparacino, 1986; Tavistano et al., 1986) with essentially the same definitions. It may be that lack of clarity about the role of specialists has affected their acceptance by other professional groups. Several works have emphasized that other nurses, in particular district nurses, were fearful that their roles were being eroded and their jobs de-skilled (Canham and Murray, 1989; Kindlen, 1987; Keller, 1973). Several researchers (Harrell and McCulloch, 1986; Wade and Moyer, 1989) have observed that there is a need for more research in Britain about the effectiveness of specialist nurses, in terms of their actual impact on patient care. Some studies have attempted to evaluate the effectiveness of specialist nurses, particularly in the areas of diabetic care (Moyer, 1987; Moyer, 1989), stoma care (MacDonald and Anderson, 1985; Wade, 1989), respiratory care (Cockcroft et al., 1987) and terminal care (Doyle, 1982; MacDonald, 1989; Parkes, 1980). But the outcome measures used, e.g. quality of life, patients dying at home, satisfaction ratings are, in the main, difficult to measure and their suitability as outcomes hard to assess. Wandsworth, a large inner city London Health Authority, decided in 1988 to appoint specialist nurses and, by the end of 1989, had three specialist HIV nurses, three nurses for the elderly, two diabetic nurses, two MacMillan nurses, two terminal care coordinators and one nurse for the physically handicapped. All worked in the community and were accountable to community nurse managers. However, by the end of 1989 there were financial constraints and an understaffed district nursing establishment which meant that the community nursing service was severely stretched. The integration of specialist nurses into the community service was acknowledged to have been neither consistent nor systematic. As a result, although a previous survey had established that district nurses were ready to accept, at the least, terminal care specialists (MacDonald and Macnair, 1986), there was potential for poor inter-staff communication, poor coordination of patient services, and for role conflicts between specialist and district nurses. It was felt that this situation might affect efficiency and effectiveness of service provision and district nurses’ job satisfaction, with consequent recruitment and turnover problems. This survey was undertaken at the request of the Unit General Manager for Continuing Care. It was designed to investigate the issues involved in management of specialists and the roles of district and specialist nurses as perceived by themselves and each other, in terms of responsibility, autonomy, skills and training, communication, role conflicts and general job satisfaction. Methods
The study population comprised all locality and neighbourhood
nurse managers in the
THE SPECIALIST
IN COMMUNITY
NURSING
39
Health Authority, all specialist nurses, and all district nurses and community staff nurses. All managers and specialist nurses were interviewed, the former with open-ended and the latter with closed-format schedules. District nurses were given a self-complete questionnaire. Both specialist and district nurses also completed a questionnaire derived from the Minnesota Nurse Satisfaction Questionnaire (MNSQ) (Ward and Fetler, 1979). This questionnaire used the same format as the MNSQ, but it was reduced from 120 to 49 questions to exclude questions that were not relevant to a community setting or were inappropriate in an English context. Some wording was changed to suit the English idiom. The original and the revised version of the MNSQ were tested for internal consistency on a group of 18 2nd year nursing students (Cronback’s alpha 0.76). The original paper had identified seven factors (or themes) using factor analysis: professional considerations, working conditions, professional preparation, pay, emotional climate, supervision and social significance. Questions from all seven factors remained in the shortened version of the questionnaire. Respondents were asked to score their answers to individual questions on a scale from 1 (very satisfied) to 4 (very dissatisfied). Answers to the questionnaire were analysed in three ways: firstly, scores of individual questions were compared between groups of nurses; secondly, scores of the questions comprising each factor were aggregated and medians of the aggregated scores for each factor were compared between groups of nurses, using a Mann-Whitney U-test; and thirdly, the proportions of each group of nurses whose scores indicated dissatisfaction (scores 3 or 4) were calculated as a percentage of total responses aggregated within each factor.
Results Nurse managers
All community nurse managers in Wandsworth were interviewed-10 neighbourhood and two locality. The majority felt that the introduction of specialist nurses had resulted in better patient care, improvement in district nurses’ knowledge and better communication between hospital and community. They also identified some resentment by district nurses that specialists, with the exception of HIV nurses, were eroding their role. Specialists were regarded as having been imposed upon rather than growing out of and extending general nursing. Although their work was seen to be worthwhile, integration of specialists into the community service was not as good as it might have been. There was lack of agreement among managers about whether specialists gave “hands-on” care, suggesting that some confusion remained about the specialist role, with potential for conflict and managerial confusion. A combined district and specialist nurse role, whereby district nurses developed their own specialities was seen by the majority of managers as the most desirable way to overcome these problems. No manager believed that the introduction of specialists had had any effect on the motivation, satisfaction or turnover of district nurses in the Health Authority. These were affected by structural factors such as chronic staff shortages, and by external factors such as the characteristics of the inner city case load, or the cost of housing in inner London. Managers felt they were not fulfilling their management role properly, some because they hardly ever saw the specialist, some because they were unsure of what management of these nurses entailed. There was confusion and lack of agreement about who actually managed individual nurses. Responses to the question, ‘Who manages specialist nurses?’ were as follows: some thought that all the nurses were managed by neighbourhood nurse managers
F. H. HASTE
40
AND
L. D. MACDONALD
(two responses), some that all were managed by locality managers (three), that neighbourhood nurse managers managed the HIV, elderly and diabetic specialists, while the locality managers managed the rest (five), that neighbourhood nurse managers managed only the HIV and diabetic specialists (one), or that neighbourhood nurse managers managed only the elderly and diabetic specialists (one). This lack of clarity suggests that accountability was poor. There was little overall enthusiasm for an increase in the number of specialist nurses in the future. Suggestions included a continence advisor, a child abuse nurse (two), mastectomy counsellor (one) and stoma care nurse (one). Three wanted fewer specialists. The majority favoured district nurses developing specializations to combine with district nursing duties. However, it was believed that specialist HIV nurses were needed because few district nurses yet had sufficient training to cope with HIV patients. Specialist and district nurses Interviews were obtained with all specialist HIV, terminal care, diabetic and elderly nurses, 12 in all. The physical handicap specialist was not interviewed. All district nurses, and all but one community staff nurse completed questionnaires, 40 altogether. (Numbers in brackets refer to number of respondents.) Role definitions. Using items from the specialists’ job descriptions and others suggested by senior nurses, a list of role elements was drawn up (Table 1). Both specialist and district Table 1. Perceptions of the role of the specialist nurse Specialist nurses (n= 12) Disagree Unsure Agree n % n Vo n % Train district nurses in speciality
11
Advise patients
12 (100) -
(92) 1
16 (40) 24 (60)
(8) -
Give hands-on care
5
(42) 7
(58) -
Be fully responsible for patients
4
(33) 8
District nurses (n = 40) Agree Disagree Unsure n % n % n Vo -**
39 (98) 1 (2) 16 (40) 21 (53)
3
(8)
9 (23) 30 (75)
1
(2)
Liaise between patient and hospital
12 (100) -
(67) -
Liaise between patient and GP
12 (100) -
-
39 (98) 33 (82)
1 (2) 7 (18)
-
(25) -
33 (82)
7 (18)
-
Liaise between district nurses and hospital Counsel patients Do research Assess needs Instruct district nurses Ensure district nurses follow instructions
9 11
(75) 3 (92)
1
(8) -
38 (95) 1 (2) 13 (33) 26 (65) 16 (40) 23 (58)
1 1 1
(2) (2) (2)
5 8
(42) 6 (67) 3
(50) (25)
4
(33) 8
(67) -
15 (38) 25 (62)
-
3
(25) 9
(75) -
7 (18) 33 (82)
-
1 1
(8) (8)
**Significant difference between perceptions of specialist nurses and district nurses (x2 = 7.5, P < 0.01).
nurses were asked if they thought each element was part of the specialist role in the Health Authority. Most specialists agreed that it was part of their role to train other nurses, advise patients and nurses, liaise between patient, hospital and GP, and to counsel patients. The majority believed that providing hands-on care, being responsible for patients overall, concentrating on research, giving instructions to district nurses and ensuring that instructions
THE SPECIALIST
IN COMMUNITY
41
NURSING
were carried out were not part of their role. The opinions of district nurses were very similar, except that they were considerably less likely to feel that training other nurses in their speciality was part of the specialist role. Fulfilment of the specialist nurse role Specialist nurses were asked about what they actually did. District nurses were also asked about hands-on care provided by the specialist. Although most specialists said their role involved training other health professionals (1 l), some (three) provided neither formal nor informal education. One spent six hours/week in formal teaching; the others offered few formal sessions. Some said they did no informal teaching (two), while others spent “about half the time” (three) or “all the time” (three) informally educating nursing staff. Most agreed that counselling patients was part of their role (11). Many estimated that half or more of their time with patients was spent in counselling (nine). Only a minority had been involved in research. Two were employed on an existing trial and three had participated in research at some time. Two specialists, both HIV nurses, said they routinely gave hands-on care, others said they would in an emergency, or when district nurses were not available (eight). This latter circumstance was observed to be becoming increasingly common as the crisis in district nurse staffing continued. Among district nurses, 40% felt that hands-on care was part of the specialist role. A small minority said that specialists routinely provided hands-on care, although more said they would in an emergency. A higher proportion of district nurses than specialists said the latter should be giving hands-on care routinely (Table 2).
Table 2. (a) Do specialist nurses provide hands-on District nurses’ views Terminal care Locality nurses nurses for the elderly
HIV nurses n
VO
Yes-routinely Yes-sometimes No Do not know Not applicable
4 10 10 3 13
(10) (25) (25) (8) (32)
2 10 26 2
(5) (25) (65) (5)
Total
40
(loo)*
40
(loo)*
n
(b) Should
Yes-routinely Yes-sometimes No Do not know Not applicable No response
13 12 7 1 7 -
(33) (30) (18) (2) (18)
Total
40
(loo)*
*Some totals
%
n
1 40
do not add up to 100 due to rounding.
(25) (43) (28) (2)
Diabetic nurses
%
n
10 22 8
(0) (25) (55) (20)
4 17 14 4 1
(10) (43) (35) (10) (2)
40
(loo)*
40
(loo)*
17
(43)
18 5
(4:) (13) 0 0
40
(loo)*
specialist nurses provide hands-on District nurses’ views 10 17 11 1
care?
5 20 13 -
(13) (50) (33)
(2)
2
(5)
(lOO)*
40
(loo)*
070
care?
42
F. H. HASTE
AND L. D. MACDONALD
Perceived effectiveness of specialist nurses Acting as a resource person was defined as a major element of the specialist role. To ascertain how effective specialists were in fulfilling this role, district nurses were asked whether having specialists had improved their knowledge. The majority said they had increased their knowledge of how to care for terminally ill (62%) and diabetic patients (80%). One-third had no option about HIV nurses due to lack of contact, but of the rest, 70% said their knowledge of HIV conditions had improved. Nurses for the elderly were thought to have reduced the numbers of inappropriate discharges (70%). Perceptions of communication between specialist and district nurses differed between the two groups. All specialists felt that communication was good or very good while 22% of district nurses said that communication was poor or very poor. However, 86% of district nurses felt that communication between hospital and district nurses had been improved, particularly by the efforts of the nurses for the elderly (86%). Two-thirds of both district and specialist nurses agreed that formal meetings between them should be increased. District nurses also wanted more meetings with specialists at patients’ homes (85%). In their liaison role, the majority of specialists felt that communication between themselves and the hospital was very good (six) or adequate (four). Liaison with GPs was less satisfactory and communication with them was seen to be poor or very poor (five), and needed to be improved (10). GPs were thought to have a very poor understanding of the specialist role and were reluctant to use these nurses (four). Usefulness of specialist nurses’ work The usefulness of specialists to others nurses and to patients was assessed by asking both district and specialist nurses to rank eight aspects of the specialist role. Rankings have been grouped as l-3 (high), 4-5 (medium), 6-8 (low) and 0 (no usefulness). Usefulness to nurses. District nurses most often ranked counselling highest, followed by advising patients and giving information/advice to nurses (Table 3). Formal teaching was given low ranking overall. There was little agreement about coordination of medical care or assessment of needs-almost equal proportions ranked these as being of high, medium and low/no usefulness. Hands-on care was most frequently ranked as of low/no usefulness. Specialist nurses ranked advice to patients (nine), coordination of care (seven) and advice to nurses (six) highest. Research and hands-on care were regarded as least useful (nine). Specialists were less likely than district nurses to rank counselling patients as useful to other nurses (half vs three-quarters). Usefulness to patient care. District nurses regarded the most useful aspects as counselling patients, advising patients and advising nurses. There was less agreement over needs assessment, coordination of care and formal teaching. Hands-on care was again most frequently ranked as of low or no usefulness. Among specialists, advice to patients (nine), needs assessment (seven) and counselling patients (six) were ranked as being of high usefulness. Hands-on care (10) and formal teaching of health professionals (six) were ranked as of low/no usefulness to patient care. Role conflict District nurses were asked several questions about whether specialists were eroding the traditional district nurse role. Depending on the speciality, 20-50% felt that specialist nurses routinely or sometimes did work that district nurses should be doing (Table 4). The majority (53%) preferred to assess the elderly themselves, an additional 5% wanting some specialist backup.
THE SPECIALIST
IN COMMUNITY
43
NURSING
Table 3. District nurses’ perception of the usefulness of aspects of the specialist role High (rank l-3)’ % n
n=40 Medium Low (rank 4-5)* (rank 6-S)* n
070
n
Not useful (rank 0)*
%
n
%
Missing n
%
(i) to district nurses Role aspects Formal teaching Needs assessment Counselling Advice to nurses Research Coordination of care Advice to patients Hands on care
7
(18)
15 31 24 7 13 21 1
(38) (78)
w
(18) (33) (68) (2)
11 I 4 10 2 11 4 7
(28) (18) (10) (5) (5) (28) (10) (18)
9 13 2 1;:
(22) (32) (5) ,::i
9 6 20
(22) (15) (50)
9 2
(22) (5)
1 1: 3
(2) ,::; (8)
:
,:;;
1 5 3 0 4 3 :
(3) (13) (8)
4 3
4 2 3
(10) (8) (5) (5) (8) (10) (5) (8)
6 6 6 5 6 5 5 6
(15) (15) (15) (13) (15) (13) (13) (15)
2 23
(ii) to patient care Formal teaching Needs assessment Counselling Advice to nurses Research Coordination of care Advice to patients Hands on care
15 12 20 19 9 14 20 2
(38) (31) (50) (48) (22) (35) (50) (5)
9 8 10 14 5 8 10 3
(22) (21) (25) (35) (13) (20) (25) (8)
9 9 :. 16 10 4 22
(22) (22) (2) (5) (40) (25) (10) (55)
(10) (8) (2) (18)
*Nurses were asked to rank each role aspect from 1 to 8 or as not useful. Ranks l-3= high, 4-5 = medium. 6-8 = low.
Table 4. Are specialist nurses doing work that district nurses should be doing? HIV nurses
Yes-regularly Yes-sometimes No Do not know Not applicable No response Total
n
070
1 12 14 4 9 0 40
(2) (30) (35) (10) (23) (100)
District nurse responses Terminal care Locality nurses nurses for the elderly n % % n 2 20 16 2 0 0 40
(5) (50) (40) (5)
(100)
6 12 19 2 0 1 40
(15) (30) (48) (5) (2) (loo)
Diabetic nurses n % 2 6 29 1 0 2 40
(5) (15) (73) (2) (5) (100)
Nearly half (45%) preferred to care for terminally ill patients, with 20% more preferring some backup. Fewer preferred to nurse HIV patients (18% with no specialist; 25% with some backup). District nurses expressed varying degrees of uncertainty about how to care for the patient groups under consideration: HIV patients, 62% uncertain, diabetic patients 529’0, and terminally ill patients 43%. All but one mentioned the need for more training in HIV and terminal care, particularly counselling skills (6Ovo) and symptom control (66%). Threequarters felt they needed more training in diabetic care and care of the elderly. Just seven district nurses (18%) had had any post-registration courses in specific aspects of care, or care of particular categories of patients.
44
F. H. HASTE
AND
L. D. MACDONALD
Positive and negative feelings All respondents were given a series of statements expressing positive or negative feelings about the role of specialist nurses. District nurses were asked whether they agreed; specialists were asked whether they thought district nurses would agree (Table 5). Table 5. Positive and negative feelings* District nurses (n = 40) Agree n
%
Disagree n
%
Specialist nurses (n = 12)
NR
DK n
%
n
%
Agree n
%
Disagree n
DK
NR n
xZPt
%
n
%
%
(8)
1
(8)
-
0.3
5
36 (90)
3 (8)
-
1
(2)
10 (83)
Resentful 15 (38)
23 (58)
-
2
(5)
9 (75)
2 (17)
1
(8)
-
4.9 0.05
Positive
27 (68)
11 (28)
1
(2)
1
(2)
5 (42)
6 (50)
1
(8)
-
1.3
NS
Annoyed
25 (63)
11 (28)
2
(5)
2
(5)
9 (75)
3 (25)
-
0
NS
Confident 32 (80)
7 (18)
1
(2)
8 (67)
4 (33)
-
0.5
NS
1
(2)
9 (75)
2 (17)
1
(8)
-
3.1
NS
2
(5)
7 (58)
4 (33)
1
(8)
-
5.2 0.05
Relieved
Anxious
18 (45)
20 (50)
Indignant
9 (23)
29 (73)
-
1
(2) -
1
NS
*Responses of district and specialist nurses to the statements “I think district nurses feel . . . about specialists”. tcomparison of district and specialist nurses for each question. Missing values excluded. NS = not significant; DK = don’t know; NR = no response.
District nurses were generally favourable about the role of specialist nurses. Most agreed with the positive statements and a majority disagreed with all but one negative statement. Most agreed that: “district nurses feel angry because they are not always informed of what specialist nurses are doing”. Specialists had a more negative view of what district nurses felt about them and felt that district nurses would be more likely to agree with the negative statements. Management of specialist nurses Specialist nurses were asked who managed them, whether their manager was appropriate, and whether they had enough contact with and support from their manager. Each group of specialists agreed about who managed them. Seven felt their manager was appropriate. Five felt they did not have enough contact with their managers and six that they did not get enough support. Job satisfaction District nurses expressed significantly more dissatisfaction than specialists, with higher dissatisfaction scores on the factors emotional climate, professional considerations, social significance, pay and professional preparation. They also tended to be more dissatisfied with working conditions (Table 6). The distribution of factor scores (Table 7) shows that district nurses were least satisfied with working conditions, pay and professional preparation.
THE SPECIALIST
IN COMMUNITY
45
NURSING
Table 6. Aggregated factor scores on nurse satisfaction questionnaire Factor (number of questions: possible range for factor)
Specialist nurses median (range) 92.5
District nurses median (range)
P
