RESEARCH
The unique contribution of community clinical nurse specialists in rural Wales Debbie Roberts, Pat Hibberd, Christopher Alan Lewis, Joanne Turley
Debbie Roberts, Reader in Nursing, Pat Hibberd, Principal Lecturer in Health Sciences, Christopher Alan Lewis, Professor of Psychology, Joanne Turley, Graduate Teaching Assistant, Academic Division of Psychology, Sport Science and Health, ˆ University, Wrexham, Wales Glyndwr Email: [email protected]
E
xisting key quality care indicators for nursing in the UK focus on health-associated infection, pressure ulcers, falls, drug administration errors, and patient complaints (Maben et al, 2012). However, standardisation of these is lacking, resulting in difficulties in benchmarking between organisations or wards/ units. Previous research has established links between staff wellbeing and positive patient experiences of care, staffing and skill mix, and positive patient outcomes in community care (Maben et al, 2012). The Community Nursing Research Strategy for Wales (2013) identifies the evaluation of the impact and value of community nurses as a priority, putting this innovative project at the forefront of community nursing research. This article describes the approach taken to identify the consensus view among specialist nurses regarding their unique nursing contribution within a rural community. This research was carried out with a view to subsequently develop quality metrics that service provision could be measured against, thereby contributing to an evidence base that is currently lacking. The research formed part of a larger service evaluation commissioned by the Director of Nursing. The clinical nurse specialists in the study all work in what the Welsh Government has defined as a rural area and, while it is difficult to find agreed definitions of rurality (Prior et al, 2010), this study reflects the unique contribution of these nurses to this rural population.
kilometre and is defined as sparsely populated.The population as a whole enjoys better health than the Welsh average a, although there are significant inequalities across the area and access to the nearest district general hospital is limited by distance. The population is generally older than the average age in Wales, with fewer children and young people than the Welsh average (Davies et al, 2008).
Literature This definition of rurality is mirrored elsewhere—for example, in Canada (Hunsberger et al, 2009). In Wales,
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Background The demography of rural Wales is changing, with a shift towards an older rural population with associated health needs (Davies et al, 2008). Typically, rural areas have a population density of fewer than 150 persons per square kilometre. Prior et al (2010) note that definitions of rurality are varied—for example, within the UK, the Office for National Statistics (2004) refers to populations of less than 10 000 as being rural and those with a population of above 10 000 as being urban. Geographically, the area in which this study takes place has 26 people per square
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ABSTRACT
To date, quality indicators that have been developed for nursing tend to focus on acute, secondary care settings. It remains unclear whether such quality indicators are applicable to community settings, particularly in rural environments. This research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Identifying agreed aspects of the unique role within the rural community area will enable quality care metrics to be developed, allowing specialist nurses to measure their unique contribution to rural health care in the future. The research used the Delphi technique to identify a consensus view among a population of specialist community nurses working in a designated rural area in Wales. The strongest area of consensus related to clinical and teaching expertise, where participants perceive educational expertise as being at the forefront of their role. In terms of care for individuals, consensus was focused on four main areas: developing appropriate criteria for referral in to the service, collaborative working, education, and advocacy roles. The findings highlight similarities to models of care provision elsewhere. Specific quality indicators are required for clinical nurse specialists working in rural areas. Current quality indicators may not be applicable across all clinical settings. Further work is required to explore the nature of rural nursing practice.
KEY WORDS
w Clinical nurse specialists w Nursing roles w Quality indicators w Rural nursing w Delphi technique
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RESEARCH
Aims of study The present research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Specifically, three research questions are addressed:
602
w What is the consensus view among specialist nurses of their unique nursing contribution within their rural community? w What aspects of the unique role are common to all specialist nurses within the defined community rural area? w What quality care metrics can be developed that enable specialist nurses to measure their unique contribution to rural health care?
Method Sample
All 24 community specialist nurses working in a rural county in Wales were invited to participate in the study. These included specialist nurses who directly affected pathways of care. Some titles were related to disease pathways (cardiac, palliative care, diabetes, respiratory, Parkinson’s disease and continence) while other titles were more generic (such as pain management and tissue viability). It is important to note that in considering the term ‘community specialist nurse’, the study has included all nurses with the title ‘specialist nurse’ who had a direct impact on a defined pathway of care within the community. Therefore, emergency nurse practitioners, complex care specialist nurses and those from women and children’s services were excluded. For round 1, all 24 nurses participated. In round 2, 16 nurses participated (67%). The 16 participants had a mean age of 47.07 years (standard deviation (SD)=4.45).
Measurement The Delphi technique enables the articulation of the unique role and contribution of specialist nurses by gathering and rating their expert opinion about their roles. This was achieved through an iterative process similar to the approach taken in previous work with district nurses (Irvine, 2005). The process began with an initial survey questionnaire to establish the Delphi criteria. Following this, in real time over the course of a day, the second (and any subsequently required) questionnaires were administered and analysed to evaluate expert responses (Irvine, 2005).The Delphi technique provides a group communication process that pools the judgment of experts and is useful where available evidence is limited (Linstone and Turoff, 2002). One benefit of the Delphi technique is that it explores areas of disagreement as well as agreement, and it has three characteristics: anonymity, iteration, and controlled feedback with statistical analysis of group responses (Rowe and Wright, 2001). Two rounds of the Delphi study were conducted. In round 1, a questionnaire was adapted from an articulation of the clinical nurse specialist role within the Canadian health-care system (McMaster University, 2012). McMaster University (2012) identifies three key contributions of clinical nurse specialists in Canadian health care: better care for individuals, better health for populations and lower health-care costs, also presenting a range of role criteria under each of these themes. These themes and cri-
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there are nine designated rural authorities. Access to services may be particularly difficult for the older population in rural Wales, many of whom are living with complex medical conditions and require specialist care closer to home. This care may be provided or coordinated through the input of clinical nurse specialists. It is important to note, however, that health beliefs and values, together with help seeking behaviours, may also differ among rural populations where access to care is difficult. In a study conducted in Montana (USA), Lee and Winters (2004) explored the health perceptions and needs of 38 adults living in 11 rural communities and found that participants were self-reliant, using self-care interventions such as ‘wait and see’, home remedies or over-the-counter medicines, consultation with family members or choosing to ‘gut it out’ (Lee and Winters, 2004: 56), although it remains unclear whether those living in rural areas elsewhere display similar traits of stoicism. To date, key quality indicators for nursing have focused on acute secondary care provision. It remains unclear whether such indicators are applicable or able to accurately reflect the work of specialist community nurses working in rural areas. Hegney and McCarthy (2000) are of the opinion that nurses working in rural areas in Australia need to be multi-skilled generalists who regularly make important decisions, often in the absence of other health professionals. Therefore, the impact of working as specialist is brought into question. While Hunsberger et al (2009) suggest that Canadian rural nurses are generalists who require multi-specialist knowledge and skills in order to respond to their diverse populations and the flexibility to assume numerous roles and multitask when working alone. The role undertaken by those involved in the present sample are all population ‘nurse specialists’. There may be elements of their role that are both specialist and generalist. This lack of clarity regarding the role and terminology is unhelpful when trying to make international comparisons. This debate is well documented in the literature (Gray et al, 2011; Canales and Drevdahl, 2014). Whether the nurses working in community roles are specialists or generalists, there may be added value contributions attributable to health-care institutions and the individuals involved that, to date, have not been amenable to measurement (Prior et al, 2010). Prior et al describe these as ‘multiple dimensions of human capital to remote communities’ (Prior et al, 2010: 1142). This might be particularly true for community specialist nurses in the UK, although it seems that evidence regarding the impact of community nurses is limited. Queen’s Nursing Institute (2014) calls for community nursing to identify and articulate a clearer vision to include an expression of values in order to address ‘the crisis of professional identity’.
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RESEARCH teria were deconstructed and adapted in order to produce a 31-item questionnaire that would enable the clinical nurse specialists to begin identifying their own contribution, similarities and differences within their own role criteria. Although this was based on a Canadian model, the specialist nurses consulted felt that, for round 1, this would be suitable for reflecting and articulating the contribution of their role. The questionnaire was then piloted with a sample of the specialist nurses during a workshop activity; no new items were added or changed as a result of this. The questionnaire sought to obtain broad data and was delivered electronically to the total population. Participants were asked to consider whether items either applied to their role or should apply. Participants were also asked to provide details about whether the items should be measured or how they were being measured.
Questionnaire categories The initial questionnaire examined four distinct categories. Section 1 explored the background role criteria and demographic information, such as the educational status and skills of the practitioner, in an attempt to draw conclusions regarding commonalities and differences in qualifications (professional and academic), role descriptors and experience. The remaining sections were seeking a consensus view and followed the approach taken by McMaster University in their exploration. Section 2 focused on better care for individuals, and included risk management and quality improvement. Section 3 considered better health for populations, such as consultation on complex disease management and expert advice to other practitioners. Section 4 concentrated on lower costs, such as reduced hospital admissions and shorter lengths of stay in acute care.
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Questionnaire development Although the questionnaire was sent to individuals, some specialist nurse teams returned the questionnaire and identified the criteria that applied to their service and whether or how particular items were measured. Because some teams submitted responses, it is not possible to say how many individuals contributed to the completion of round 1. The criteria and various measures identified were then subsequently developed into a 72-item questionnaire that would be utilised for round 2 and incorporated the following sections: Section 1 focused on the role criteria; Section 2 explored better care for individuals; Section 3 considered quality improvement; and Section 4 concentrated on better health for populations. A copy of the 72-item questionnaire can be obtained from the first-named author upon request. In round 2, all 24 nurses were again invited to participate, with 16 consenting to do so. The 16 participants for round 2 were brought together in the same location and the 72-item questionnaire was administered. Participants were asked to indicate their agreement with these emerging statements according to a five-point Likert scale (1 = ‘strongly disagree, 2 = ‘disagree’, 3 = ‘uncertain’, 4 =
‘agree’, 5 = ‘strongly agree’). For these data, all responses were anonymous. The computer software SPSS version 21 was used to identify the level of consensus (or agreement) expressed as a mean score along with a standard deviation. Data presented relate to this round. Data reported relate to the areas where agreement was strongest in each section. Demographic information was also collected (e.g. length of service).
Results and discussion In total, 16 responses were returned, giving a 100% response rate for round 2. The responses from the round 2 questionnaires were entered into SPSS V21 and mean and standard deviation (SD) scores for each item were calculated. The mean length of service (in months) was 104.38 (SD=69.92). Four participants (25%) were advanced practitioners, 11 (68.8%) were not advanced practitioners, and 1 participant did not respond. Six participants (37.5%) were non-medical prescribers, while the remaining 10 (62.5%) stated they were not non-medical prescribers. When asked about their highest academic qualification, 3 (18.8%) had masters degrees, 5 (31.3%) had completed one or more masters modules, 4 (25%) held a postgraduate certificate in education (PGCE), 3 (18.8%) had a bachelor of science (BSc) degree, and 1 (6.3%) was qualified to diploma level.This variation in educational and professional qualifications of participants illustrates the diversity of routes to working as a specialist in the community setting. The mean age of participants was 47.07 years (SD=4.45), which also highlights the ageing workforce.
Consensus From this round, it is clear that consensus occurred, with all 72 items achieving a mean score of greater than 3 and a standard deviation of below 1.2, indicating that the participants support the principles held in these statements. This phenomenon is perhaps not surprising, as it was the panellists who developed the statements in the initial stage of the Delphi study. The occurrence is further highlighted by the fact that no item achieved a mean score of below 3, indicating that the panellists did not collectively disagree with any of the items (Figure 1). Thereafter, when a mean score of 4 or more was achieved on any individual item, that item was retained. This resulted in 60 of the original 72 items being retained and 12 being removed from the subsequent analysis (Figure 2). The Delphi survey collected data relating to role profile, better care for individuals, quality improvement and better health for populations. The areas where there was strongest consensus in each section are reported here, although the mean scores for all 72 items can be obtained from the first-named author upon request.
Role profile Within the role profile theme, 24 of the 27 items attained mean scores of 4.0 and above, ranging from 4.00 (SD=0.73) to 4.94 (SD=0.25), indicating the panels’ acceptance of the
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RESEARCH nurse specialists in the care of older adults in assisted living lodges that include coaching and guidance of professional and non-professional staff, collaborative care and consultation services for other health-care providers, resulting in improved patient and health provider uptake of best practice (Bryant-Lukosius et al, 2010). This is described as the added value of the clinical nurse specialist role in the Canadian study, but rather than adding value, it would seem that the community clinical nurse specialists in this study perceive such activity to be at the forefront of the role.
1.2
0.8 0.6 0.4
Better care for individuals
0.2 0 0
1
2
3 Mean
4
5
6
Figure 1. Mean values and standard deviation in round 2 of survey showing level of agreement on all questionnaire responses 1.2
Standard deviation
1 0.8 0.6 0.4 0.2 0 0
1
2
3 Mean
4 6
5
Figure 2. Graph showing responses with a mean of 4 or above in round 2 of survey
competencies portrayed in these items. The three items with the highest mean scores are shown in Table 1. Using content analysis, two categories—clinical advice and teaching expertise—were identified as being relevant, both of which were identified as common to all their roles. The educator function features in clinical nurse specialist roles in Canada and Australia, so it is perhaps unsurprising that this element gained the greatest consensus within the group. The area with the greatest level of confidence and agreement involves provision of expert advice to other nurses. This element confirms the ‘clinical expert’ nature of the role and suggests that specialist nurses see themselves as a valuable resource for others. In Canada, for example, specialised expertise and leadership is provided by clinical
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Within the ‘better care for individuals’ theme, all 14 of the 15 items attained mean scores of 4.0 and above, ranging from 4.12 (SD=0.81) to 4.75 (SD=0.45), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 2. Through content analysis, four categories were identified as relevant: developing appropriate criteria for referral into the service, collaborative working, education, and advocacy roles. During discussions regarding referral into the services offered by the community specialist nurses, it became clear that some services had already developed criteria and robust systems for referral, while others relied on openaccess models of referral. Indeed, some services questioned the concept of inappropriate referrals, believing that all individuals being referred into the service should be assessed. Nonetheless, the group agreed that systems and criteria for referral in to the service should be articulated. While there was a strong consensus that one of the main elements of community nurse specialists’ work focuses on collaborative interprofessional working, there are no mechanisms for recording the nature of such collaboration, or the benefits that this has on patient outcome. Similarly, the participants reached a strong level of consensus regarding the need for an advocacy role in order to develop health and social services that best meet patient needs.While many of the participants felt that this was self-evident, a question remains regarding how such work could be articulated in terms of patient outcome. Other countries such as Greenland have developed rural community nursing roles to include not only traditional clinical care, but also tasks related to medical treatment and social work in order to provide meaningful services to the rural population (Hounsgaard et al, 2013). The study highlights the importance of being able to undertake a range of non-clinical tasks such as shovelling snow and applying salt-grit to pavements, distributing post and being an all-round community worker. Hounsgaard et al (2013) demonstrate the difficulties encountered for the nurses serving the remote and rural areas of Greenland in separating social work from health-related issues, and argue that nurses adapt their role to meet patient need. While the climate and geography of Greenland may play an important part in dictating role development, there may be benefits to such generic working in less sparsely populated, milder
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Standard deviation
1
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RESEARCH climates such as the UK, which, to date, have not been fully explored.
Quality improvement Within the ‘quality improvement’ theme, all 10 of the 15 items attained mean scores of 4.0 and above, ranging from 4.06 (SD=0.77) to 4.56 (SD=0.51), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 3. Through content analysis three categories were identified as relevant: measurement of quality and safety of patient care as an indication of improvements; promotion of excellence in practice by the sharing of developments; and design and implementation of service-specific evidence-based policies and practices. The notion of measuring improvements in quality and safety effectively means that the nurses would have to collect more data as part of their everyday working role to be able to demonstrate any improvement. That said, the notion of quality care in terms of rural populations may also need to be carefully articulated. It cannot be assumed that people living in urban and rural areas will have the same notions of what constitutes quality nursing care. Therefore, it is clear that further work is required to fully understand the needs and expectations of rural populations.
Better health for populations Within the ‘better health for populations’ theme, all 12 of the 15 items attained mean scores of 4.0 and above, ranging from 4.13 (SD=0.81) to 4.69 (SD=0.48), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 4.Through content analysis, three categories
were identified as relevant: a definition of the contribution of the community clinical specialist nurses being required; quality of life as a wider measure of activity being required; and the need for contribution to primary physical, functional and psychological wellbeing to be identified. This is perhaps not surprising for this participant group given the argument for health promotion in the specialist role identified by Irvine (2005) and the national strategic intention (Welsh Assembly Government, 2010) to improve selfhealth management of the population through information and knowledge. In rural areas in particular, service users may lack access to local health facilities and, therefore, as Lee and Winters (2004) argue, rural nursing interventions should allow time for assessment and discussion of health practices, self-care activities and other activities related to the maintenance of a healthy lifestyle. However, there may be a number of factors creating differences in the prioritisation of health promotion activities by specialist nurses. First, community services are moving to a ‘pull’ system, delivering more complex care closer to the patient’s home (Welsh Assembly Government, 2010). This means that those specialist nurses who are delivering chronic condition case management, admission avoidance, early discharge, prescribing and medicines management may find that the biomedical elements of their work is increasingly valued. A qualitative study of service users by Wilson et al (2012) suggests that perceptions of nurse autonomy, status and legitimacy as managers of their complex case are higher if the nurse is biomedically focused. This approach potentially diminishes the importance of a more sociologically driven or holistic health promotion role. Second, the nurses’ specialist knowledge and skills may be required for complex assessment and problem solv-
Table 1. Role profile Background/role profile
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will provide expert advice to other nurses working with patients
16
4
5
4.94
0.25
All community clinical specialist nurses will engage in teaching staff who are working with patients and carers in their caseload
16
4
5
4.94
0.25
All community clinical specialist nurses will engage in teaching patients and carers within their specialist field
16
4
5
4.94
0.25
Table 2. Better care for individuals
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Background/role profile
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will develop criteria for appropriate referral into the service
16
4
5
4.75
0.45
All community clinical specialist nurses will work collaboratively with interprofessional team members
16
4
5
4.75
0.45
All community clinical specialist nurses will advocate for health and social services that best meet patient need
16
4
5
4.75
0.45
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RESEARCH
Table 3. Quality improvement Quality improvement
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will measure improvements in quality and safety of patient care within their caseload
16
4
5
4.56
0.51
All community clinical specialist nurses will actively promote excellence in practice by sharing practice developments across the county
16
4
5
4.56
0.51
All community clinical specialist nurses will design and implement servicespecific evidence-based policies and practices
16
4
5
4.56
0.51
Mean
Standard deviation
Better health for populations
N
Minimum
Maximum
All community clinical specialist nurses will define their contribution towards enhancing the quality of life of the wider community through health promotion and education initiatives
16
4
5
4.69
0.48
A key role of all community clinical specialist nurses is to enhance the quality of life of the wider rural community through health promotion and education initiatives
16
4
5
4.69
0.48
A key role of all community clinical specialist nurses is to contribute toward enhancing the primary physical, functional and psychological wellbeing of individuals within their rural area
16
4
5
4.63
0.50
ing, whereas generic nurses are more likely to support an ongoing education and health maintenance programme. In a randomised controlled study of specialist nursing with renal patients, Wong et al (2010) used specialist nurses to make initial assessments, identify problems and set mutual goals and generic nurses for subsequent calls for health advice and reinforcement of behaviours and found that this model had an overall positive effect in the study group. These studies suggest that, while recognising the importance of health promotion in the role, some specialist nurses may find that they need to prioritise complex case management, drawing heavily on specialist knowledge and advanced clinical skills. However, the study by Proctor et al (2013) suggests that the development of nursing roles in integrated care systems is idiosyncratic and unsystematic. It is therefore possible that the specialist contribution to wider health promotion initiatives needs further systematic definition in conjunction with roles that other nurses and health professionals in the integrated rural team are undertaking.
Conclusion The Delphi technique enabled participants to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Articulating the areas of strongest agreement and commonality of the specialist role is an important first step in enabling the specialist nurse group to gain consensus on priority areas for future measurement across the service. Having identified these, the next step for the team is to articulate these areas of consensus into a set of cross-service
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quality metrics that can then be tested and measured. Nurses must have responsibility for actions that lead to the outcome (in terms of legitimate authority, self-perception and sphere of practice) (Griffiths et al, 2008). The findings presented here highlight similarities to both Australian and Canadian models of care provision, in the sense that community clinical nurse specialists in the UK are required to undertake a role that includes clinical expertise, managing the care of complex populations, educating and supporting other interdisciplinary colleagues and influencing or facilitating change. Prior to this survey, the quality-care metrics available to nurses focused on acute, secondary care provision. The areas of consensus and shared practices unearthed by this Delphi survey go some way to articulating the real world of community clinical nurse specialists. This consensus highlights that specific quality indicators are required for such an important group of care providers. It is clear that more work is required to articulate relevant and appropriate specific and measurable outcomes for these indicators, which can then be tested further in rural and urban community settings. As a study design, the Delphi technique helps to empower expert practitioners to identify aspects of the role that are most amenable to measurement and then to consider ways in which other hidden aspects of the role could be made more visible. In reviewing and re-clarifying the role, the study design is inherently empowering. The clinical nurse specialists that participated in this study are able to articulate areas of strong consensus concerning their unique nursing contribution. The quality indicators identified by this group of nurses are amenable
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Table 4. Better health for populations
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RESEARCH to testing and may be significant to other nurse specialists, particularly those working in rural areas. BJCN
of health services in remote Scotland and Australia. Health and Place 16(6): 1136–44. doi: 10.1016/j.healthplace.2010.07.005 Proctor S, Wilson PM, Brooks F, Kendall S (2013) Success and failure in integrat-
Bryant-Lukosius D, Carter N, Kilpatrick K et al (2010) The clinical nurse specialist role in Canada. Nurs Leadersh 23: 140–66 Canales MK, Drevdahl DJ (2014) Community/public health nursing: is there a future for the speciality? Nurs Outlook, in press. Epub ahead of print 7 July. doi: 10.1016/j.outlook.2014.06.007 Community Nursing Research Strategy for Wales (2013) Community Nursing Research Strategy for Wales: executive summary. Workshop presented at Holiday Inn, Cardiff, 21 March. http://tinyurl.com/nro6an9 (accessed 22 October 2014) Davies P, Deaville J, Randall-Smith J (2008) Health in rural Wales: a research report to support the development of the Rural Health Plan for Wales. Institute for Rural Health, Final Report. http://tinyurl.com/npdkmb8 (accessed 22 October 2014) Gray C, Hogg R, Kennedy C (2011) Professional boundary work in the face of change to generalist working in community nursing in Scotland. J Adv Nursing 67(8): 1695–1704 Griffiths P, Jones S, Maben J, Murrells T (2008) State of the Art Metrics for Nursing: A Rapid Appraisal. National Nursing Research Unit, Kings College, University of London. http://tinyurl.com/beu3twk (accessed 22 October 2014) Hegney D, McCarthy A (2000) Job satisfaction and nurses in rural Australia. J Nurs Admin 30(7/8): 347–50 Hounsgaard L, Jensen AB, Wilche JP, Dolmer I (2013) The nature of nursing practice in rural and remote areas of Greenland. Int J Circumpolar Health 72: 20964. doi.org/10.3402/ijch.v72i0.20964 Hunsberger M, Baumann A, Blythe J, Crea M (2009) Sustaining the rural workforce: nursing perspectives on worklife challenges. J Rural Health 25(1): 17–25. doi: 10.1111/j.1748-0361.2009.00194.x Irvine F (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique. J Clin Nursing 14(8): 965–75. doi: 10.1111/j.1365-2702.2005.01193.x Lee HJ, Winters CA (2004) Testing rural nursing theory: perceptions and needs of service providers. J Rural Nurs Health Care 4(1): 51–63 Linstone HA, Turoff M, eds (2002) The Delphi Method:Techniques and Applications. Addison Wesley, Reading Maben J, Morrow E, Ball J, Robert G, Griffiths P (2012) High-quality Metrics for Nursing Care. National Nursing Research Unit. King’s College London. http://tinyurl.com/pm4c79b (accessed 22 October 2014) McMaster University (2012) The Clinical Nurse Specialist: Getting a Good Return on Healthcare Investment. http://tinyurl.com/neqq4vu (accessed 22 October 2014) Office for National Statistics (2004) Rural–urban classification. Department for Environment, Food & Rural Affairs. http://tinyurl.com/q8x98y6 (accessed 22 October 2014) Prior M, Farmer J, Godden DJ,Taylor J (2010) More than health: the added value
ed models of nursing for long-term conditions: multiple case studies of whole systems. Int J Nurs Stud 50: 632–43. doi: 10.1016/j.ijnurstu.2012.10.007 Queen’s Nursing Institute (2014) 2020 Vision: 5 Years On: Reassessing the Future of District Nursing. http://tinyurl.com/q8x98y6 (accessed 22 October 2014) Rowe G, Wright G (2001) Expert opinions in forecasting: role of the Delphi technique. In: Armstrong JS. ed, Principles of Forecasting: A Handbook for Researchers and Practitioners. Springer Science, New York Welsh Assembly Government (2010) Setting the Direction: Primary and Community Services Strategic Delivery Programme. Welsh Assembly Government, Cardiff. http://tinyurl.com/njrmn8w (accessed 22 October 2014) Wilson PM, Brooks F, Proctor S, Kendall S (2012) The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from a multiple case study design in England and Wales. Int J Nurs Stud 49: 2–14. doi: 10.1016/j.ijnurstu.2011.10.023 Wong FKY, Chow SKY, Chan TMF (2010) Evaluation of a nurse-led disease management programme for chronic kidney disease: a randomized controlled trial. Int J Nurs Stud 47(3): 268–78. doi: 10.1016/j.ijnurstu.2009.07.001
KEY POINTS w Clinical and teaching expertise was deemed to be most important for the clinical specialist nurses involved in the study
w The research indicates that the role of clinical specialist nurses working in rural Wales is similar to that in other countries in terms of the requirement to provide clinical expertise, education and ability to influence change
w Agreed definitions of community clinical nurse specialists are required
Support and care for patients with long-term conditions Helen McVeigh
About the book
§ Each chapter presents learning points, using a reflective approach
Like other books in this series, Fundamental Aspects of Long-Term Conditions provides a succinct, useful basis from which both student nurses and adult nurses can extend their knowledge and skills.
§ Essential guide to long-term conditions, exploring the key principles of About the author
practice, skills and policy
Helen McVeigh is a Senior Lecturer in Primary Care at De Montfort University Leicester. She is a qualified District Nurse. She has over 20 years experience of working in Primary Care working in both rural and inner city practices.
Other titles in the Fundamental Aspects of Nursing series: Children & Young Peoples Nursing Procedures Community Nursing Complementary therapies Finding Information Mental Health Nursing
Nursing Adults with Respiratory Disorders Nursing the Acutely Ill Adult Pain Assessment & Management Palliative Care Nursing 2nd edition Research for Nurses
Editor: John Fowler ISBN-13: 978-1-85642-392-2; 234 x 156 mm; paperback; 280Seriespages; publication 2010; £24.99
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§ Case history examples included to illustrate issues discussed
Fundamental Aspects of
Fundamental Aspects of Long-Term Conditions
Providing support and care for individuals with a long-term condition is an essential feature of modern health care. Over 15 million people in England currently have a long-term condition, and it is predicted that these numbers will continue to rise. Treating the range of long-term conditions that affect the population will therefore play an important role for health professionals. This book is an essential guide to long-term conditions, exploring the key principles of practice, skills and policy. The chapters in this book can be read as stand-alone chapters, or the book can be read in sequence. Full references are provided.
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The unique contribution of community clinical nurse specialists in rural Wales Debbie Roberts, Pat Hibberd, Christopher Alan Lewis, Joanne Turley
Debbie Roberts, Reader in Nursing, Pat Hibberd, Principal Lecturer in Health Sciences, Christopher Alan Lewis, Professor of Psychology, Joanne Turley, Graduate Teaching Assistant, Academic Division of Psychology, Sport Science and Health, ˆ University, Wrexham, Wales Glyndwr Email: [email protected]
E
xisting key quality care indicators for nursing in the UK focus on health-associated infection, pressure ulcers, falls, drug administration errors, and patient complaints (Maben et al, 2012). However, standardisation of these is lacking, resulting in difficulties in benchmarking between organisations or wards/ units. Previous research has established links between staff wellbeing and positive patient experiences of care, staffing and skill mix, and positive patient outcomes in community care (Maben et al, 2012). The Community Nursing Research Strategy for Wales (2013) identifies the evaluation of the impact and value of community nurses as a priority, putting this innovative project at the forefront of community nursing research. This article describes the approach taken to identify the consensus view among specialist nurses regarding their unique nursing contribution within a rural community. This research was carried out with a view to subsequently develop quality metrics that service provision could be measured against, thereby contributing to an evidence base that is currently lacking. The research formed part of a larger service evaluation commissioned by the Director of Nursing. The clinical nurse specialists in the study all work in what the Welsh Government has defined as a rural area and, while it is difficult to find agreed definitions of rurality (Prior et al, 2010), this study reflects the unique contribution of these nurses to this rural population.
kilometre and is defined as sparsely populated.The population as a whole enjoys better health than the Welsh average a, although there are significant inequalities across the area and access to the nearest district general hospital is limited by distance. The population is generally older than the average age in Wales, with fewer children and young people than the Welsh average (Davies et al, 2008).
Literature This definition of rurality is mirrored elsewhere—for example, in Canada (Hunsberger et al, 2009). In Wales,
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Background The demography of rural Wales is changing, with a shift towards an older rural population with associated health needs (Davies et al, 2008). Typically, rural areas have a population density of fewer than 150 persons per square kilometre. Prior et al (2010) note that definitions of rurality are varied—for example, within the UK, the Office for National Statistics (2004) refers to populations of less than 10 000 as being rural and those with a population of above 10 000 as being urban. Geographically, the area in which this study takes place has 26 people per square
British Journal of Community Nursing December 2014 Vol 19, No 12
ABSTRACT
To date, quality indicators that have been developed for nursing tend to focus on acute, secondary care settings. It remains unclear whether such quality indicators are applicable to community settings, particularly in rural environments. This research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Identifying agreed aspects of the unique role within the rural community area will enable quality care metrics to be developed, allowing specialist nurses to measure their unique contribution to rural health care in the future. The research used the Delphi technique to identify a consensus view among a population of specialist community nurses working in a designated rural area in Wales. The strongest area of consensus related to clinical and teaching expertise, where participants perceive educational expertise as being at the forefront of their role. In terms of care for individuals, consensus was focused on four main areas: developing appropriate criteria for referral in to the service, collaborative working, education, and advocacy roles. The findings highlight similarities to models of care provision elsewhere. Specific quality indicators are required for clinical nurse specialists working in rural areas. Current quality indicators may not be applicable across all clinical settings. Further work is required to explore the nature of rural nursing practice.
KEY WORDS
w Clinical nurse specialists w Nursing roles w Quality indicators w Rural nursing w Delphi technique
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RESEARCH
Aims of study The present research aims to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Specifically, three research questions are addressed:
602
w What is the consensus view among specialist nurses of their unique nursing contribution within their rural community? w What aspects of the unique role are common to all specialist nurses within the defined community rural area? w What quality care metrics can be developed that enable specialist nurses to measure their unique contribution to rural health care?
Method Sample
All 24 community specialist nurses working in a rural county in Wales were invited to participate in the study. These included specialist nurses who directly affected pathways of care. Some titles were related to disease pathways (cardiac, palliative care, diabetes, respiratory, Parkinson’s disease and continence) while other titles were more generic (such as pain management and tissue viability). It is important to note that in considering the term ‘community specialist nurse’, the study has included all nurses with the title ‘specialist nurse’ who had a direct impact on a defined pathway of care within the community. Therefore, emergency nurse practitioners, complex care specialist nurses and those from women and children’s services were excluded. For round 1, all 24 nurses participated. In round 2, 16 nurses participated (67%). The 16 participants had a mean age of 47.07 years (standard deviation (SD)=4.45).
Measurement The Delphi technique enables the articulation of the unique role and contribution of specialist nurses by gathering and rating their expert opinion about their roles. This was achieved through an iterative process similar to the approach taken in previous work with district nurses (Irvine, 2005). The process began with an initial survey questionnaire to establish the Delphi criteria. Following this, in real time over the course of a day, the second (and any subsequently required) questionnaires were administered and analysed to evaluate expert responses (Irvine, 2005).The Delphi technique provides a group communication process that pools the judgment of experts and is useful where available evidence is limited (Linstone and Turoff, 2002). One benefit of the Delphi technique is that it explores areas of disagreement as well as agreement, and it has three characteristics: anonymity, iteration, and controlled feedback with statistical analysis of group responses (Rowe and Wright, 2001). Two rounds of the Delphi study were conducted. In round 1, a questionnaire was adapted from an articulation of the clinical nurse specialist role within the Canadian health-care system (McMaster University, 2012). McMaster University (2012) identifies three key contributions of clinical nurse specialists in Canadian health care: better care for individuals, better health for populations and lower health-care costs, also presenting a range of role criteria under each of these themes. These themes and cri-
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there are nine designated rural authorities. Access to services may be particularly difficult for the older population in rural Wales, many of whom are living with complex medical conditions and require specialist care closer to home. This care may be provided or coordinated through the input of clinical nurse specialists. It is important to note, however, that health beliefs and values, together with help seeking behaviours, may also differ among rural populations where access to care is difficult. In a study conducted in Montana (USA), Lee and Winters (2004) explored the health perceptions and needs of 38 adults living in 11 rural communities and found that participants were self-reliant, using self-care interventions such as ‘wait and see’, home remedies or over-the-counter medicines, consultation with family members or choosing to ‘gut it out’ (Lee and Winters, 2004: 56), although it remains unclear whether those living in rural areas elsewhere display similar traits of stoicism. To date, key quality indicators for nursing have focused on acute secondary care provision. It remains unclear whether such indicators are applicable or able to accurately reflect the work of specialist community nurses working in rural areas. Hegney and McCarthy (2000) are of the opinion that nurses working in rural areas in Australia need to be multi-skilled generalists who regularly make important decisions, often in the absence of other health professionals. Therefore, the impact of working as specialist is brought into question. While Hunsberger et al (2009) suggest that Canadian rural nurses are generalists who require multi-specialist knowledge and skills in order to respond to their diverse populations and the flexibility to assume numerous roles and multitask when working alone. The role undertaken by those involved in the present sample are all population ‘nurse specialists’. There may be elements of their role that are both specialist and generalist. This lack of clarity regarding the role and terminology is unhelpful when trying to make international comparisons. This debate is well documented in the literature (Gray et al, 2011; Canales and Drevdahl, 2014). Whether the nurses working in community roles are specialists or generalists, there may be added value contributions attributable to health-care institutions and the individuals involved that, to date, have not been amenable to measurement (Prior et al, 2010). Prior et al describe these as ‘multiple dimensions of human capital to remote communities’ (Prior et al, 2010: 1142). This might be particularly true for community specialist nurses in the UK, although it seems that evidence regarding the impact of community nurses is limited. Queen’s Nursing Institute (2014) calls for community nursing to identify and articulate a clearer vision to include an expression of values in order to address ‘the crisis of professional identity’.
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RESEARCH teria were deconstructed and adapted in order to produce a 31-item questionnaire that would enable the clinical nurse specialists to begin identifying their own contribution, similarities and differences within their own role criteria. Although this was based on a Canadian model, the specialist nurses consulted felt that, for round 1, this would be suitable for reflecting and articulating the contribution of their role. The questionnaire was then piloted with a sample of the specialist nurses during a workshop activity; no new items were added or changed as a result of this. The questionnaire sought to obtain broad data and was delivered electronically to the total population. Participants were asked to consider whether items either applied to their role or should apply. Participants were also asked to provide details about whether the items should be measured or how they were being measured.
Questionnaire categories The initial questionnaire examined four distinct categories. Section 1 explored the background role criteria and demographic information, such as the educational status and skills of the practitioner, in an attempt to draw conclusions regarding commonalities and differences in qualifications (professional and academic), role descriptors and experience. The remaining sections were seeking a consensus view and followed the approach taken by McMaster University in their exploration. Section 2 focused on better care for individuals, and included risk management and quality improvement. Section 3 considered better health for populations, such as consultation on complex disease management and expert advice to other practitioners. Section 4 concentrated on lower costs, such as reduced hospital admissions and shorter lengths of stay in acute care.
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Questionnaire development Although the questionnaire was sent to individuals, some specialist nurse teams returned the questionnaire and identified the criteria that applied to their service and whether or how particular items were measured. Because some teams submitted responses, it is not possible to say how many individuals contributed to the completion of round 1. The criteria and various measures identified were then subsequently developed into a 72-item questionnaire that would be utilised for round 2 and incorporated the following sections: Section 1 focused on the role criteria; Section 2 explored better care for individuals; Section 3 considered quality improvement; and Section 4 concentrated on better health for populations. A copy of the 72-item questionnaire can be obtained from the first-named author upon request. In round 2, all 24 nurses were again invited to participate, with 16 consenting to do so. The 16 participants for round 2 were brought together in the same location and the 72-item questionnaire was administered. Participants were asked to indicate their agreement with these emerging statements according to a five-point Likert scale (1 = ‘strongly disagree, 2 = ‘disagree’, 3 = ‘uncertain’, 4 =
‘agree’, 5 = ‘strongly agree’). For these data, all responses were anonymous. The computer software SPSS version 21 was used to identify the level of consensus (or agreement) expressed as a mean score along with a standard deviation. Data presented relate to this round. Data reported relate to the areas where agreement was strongest in each section. Demographic information was also collected (e.g. length of service).
Results and discussion In total, 16 responses were returned, giving a 100% response rate for round 2. The responses from the round 2 questionnaires were entered into SPSS V21 and mean and standard deviation (SD) scores for each item were calculated. The mean length of service (in months) was 104.38 (SD=69.92). Four participants (25%) were advanced practitioners, 11 (68.8%) were not advanced practitioners, and 1 participant did not respond. Six participants (37.5%) were non-medical prescribers, while the remaining 10 (62.5%) stated they were not non-medical prescribers. When asked about their highest academic qualification, 3 (18.8%) had masters degrees, 5 (31.3%) had completed one or more masters modules, 4 (25%) held a postgraduate certificate in education (PGCE), 3 (18.8%) had a bachelor of science (BSc) degree, and 1 (6.3%) was qualified to diploma level.This variation in educational and professional qualifications of participants illustrates the diversity of routes to working as a specialist in the community setting. The mean age of participants was 47.07 years (SD=4.45), which also highlights the ageing workforce.
Consensus From this round, it is clear that consensus occurred, with all 72 items achieving a mean score of greater than 3 and a standard deviation of below 1.2, indicating that the participants support the principles held in these statements. This phenomenon is perhaps not surprising, as it was the panellists who developed the statements in the initial stage of the Delphi study. The occurrence is further highlighted by the fact that no item achieved a mean score of below 3, indicating that the panellists did not collectively disagree with any of the items (Figure 1). Thereafter, when a mean score of 4 or more was achieved on any individual item, that item was retained. This resulted in 60 of the original 72 items being retained and 12 being removed from the subsequent analysis (Figure 2). The Delphi survey collected data relating to role profile, better care for individuals, quality improvement and better health for populations. The areas where there was strongest consensus in each section are reported here, although the mean scores for all 72 items can be obtained from the first-named author upon request.
Role profile Within the role profile theme, 24 of the 27 items attained mean scores of 4.0 and above, ranging from 4.00 (SD=0.73) to 4.94 (SD=0.25), indicating the panels’ acceptance of the
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RESEARCH nurse specialists in the care of older adults in assisted living lodges that include coaching and guidance of professional and non-professional staff, collaborative care and consultation services for other health-care providers, resulting in improved patient and health provider uptake of best practice (Bryant-Lukosius et al, 2010). This is described as the added value of the clinical nurse specialist role in the Canadian study, but rather than adding value, it would seem that the community clinical nurse specialists in this study perceive such activity to be at the forefront of the role.
1.2
0.8 0.6 0.4
Better care for individuals
0.2 0 0
1
2
3 Mean
4
5
6
Figure 1. Mean values and standard deviation in round 2 of survey showing level of agreement on all questionnaire responses 1.2
Standard deviation
1 0.8 0.6 0.4 0.2 0 0
1
2
3 Mean
4 6
5
Figure 2. Graph showing responses with a mean of 4 or above in round 2 of survey
competencies portrayed in these items. The three items with the highest mean scores are shown in Table 1. Using content analysis, two categories—clinical advice and teaching expertise—were identified as being relevant, both of which were identified as common to all their roles. The educator function features in clinical nurse specialist roles in Canada and Australia, so it is perhaps unsurprising that this element gained the greatest consensus within the group. The area with the greatest level of confidence and agreement involves provision of expert advice to other nurses. This element confirms the ‘clinical expert’ nature of the role and suggests that specialist nurses see themselves as a valuable resource for others. In Canada, for example, specialised expertise and leadership is provided by clinical
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Within the ‘better care for individuals’ theme, all 14 of the 15 items attained mean scores of 4.0 and above, ranging from 4.12 (SD=0.81) to 4.75 (SD=0.45), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 2. Through content analysis, four categories were identified as relevant: developing appropriate criteria for referral into the service, collaborative working, education, and advocacy roles. During discussions regarding referral into the services offered by the community specialist nurses, it became clear that some services had already developed criteria and robust systems for referral, while others relied on openaccess models of referral. Indeed, some services questioned the concept of inappropriate referrals, believing that all individuals being referred into the service should be assessed. Nonetheless, the group agreed that systems and criteria for referral in to the service should be articulated. While there was a strong consensus that one of the main elements of community nurse specialists’ work focuses on collaborative interprofessional working, there are no mechanisms for recording the nature of such collaboration, or the benefits that this has on patient outcome. Similarly, the participants reached a strong level of consensus regarding the need for an advocacy role in order to develop health and social services that best meet patient needs.While many of the participants felt that this was self-evident, a question remains regarding how such work could be articulated in terms of patient outcome. Other countries such as Greenland have developed rural community nursing roles to include not only traditional clinical care, but also tasks related to medical treatment and social work in order to provide meaningful services to the rural population (Hounsgaard et al, 2013). The study highlights the importance of being able to undertake a range of non-clinical tasks such as shovelling snow and applying salt-grit to pavements, distributing post and being an all-round community worker. Hounsgaard et al (2013) demonstrate the difficulties encountered for the nurses serving the remote and rural areas of Greenland in separating social work from health-related issues, and argue that nurses adapt their role to meet patient need. While the climate and geography of Greenland may play an important part in dictating role development, there may be benefits to such generic working in less sparsely populated, milder
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Standard deviation
1
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RESEARCH climates such as the UK, which, to date, have not been fully explored.
Quality improvement Within the ‘quality improvement’ theme, all 10 of the 15 items attained mean scores of 4.0 and above, ranging from 4.06 (SD=0.77) to 4.56 (SD=0.51), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 3. Through content analysis three categories were identified as relevant: measurement of quality and safety of patient care as an indication of improvements; promotion of excellence in practice by the sharing of developments; and design and implementation of service-specific evidence-based policies and practices. The notion of measuring improvements in quality and safety effectively means that the nurses would have to collect more data as part of their everyday working role to be able to demonstrate any improvement. That said, the notion of quality care in terms of rural populations may also need to be carefully articulated. It cannot be assumed that people living in urban and rural areas will have the same notions of what constitutes quality nursing care. Therefore, it is clear that further work is required to fully understand the needs and expectations of rural populations.
Better health for populations Within the ‘better health for populations’ theme, all 12 of the 15 items attained mean scores of 4.0 and above, ranging from 4.13 (SD=0.81) to 4.69 (SD=0.48), indicating the panels’ acceptance of the competencies portrayed in these items. The three items with the highest mean scores are shown in Table 4.Through content analysis, three categories
were identified as relevant: a definition of the contribution of the community clinical specialist nurses being required; quality of life as a wider measure of activity being required; and the need for contribution to primary physical, functional and psychological wellbeing to be identified. This is perhaps not surprising for this participant group given the argument for health promotion in the specialist role identified by Irvine (2005) and the national strategic intention (Welsh Assembly Government, 2010) to improve selfhealth management of the population through information and knowledge. In rural areas in particular, service users may lack access to local health facilities and, therefore, as Lee and Winters (2004) argue, rural nursing interventions should allow time for assessment and discussion of health practices, self-care activities and other activities related to the maintenance of a healthy lifestyle. However, there may be a number of factors creating differences in the prioritisation of health promotion activities by specialist nurses. First, community services are moving to a ‘pull’ system, delivering more complex care closer to the patient’s home (Welsh Assembly Government, 2010). This means that those specialist nurses who are delivering chronic condition case management, admission avoidance, early discharge, prescribing and medicines management may find that the biomedical elements of their work is increasingly valued. A qualitative study of service users by Wilson et al (2012) suggests that perceptions of nurse autonomy, status and legitimacy as managers of their complex case are higher if the nurse is biomedically focused. This approach potentially diminishes the importance of a more sociologically driven or holistic health promotion role. Second, the nurses’ specialist knowledge and skills may be required for complex assessment and problem solv-
Table 1. Role profile Background/role profile
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will provide expert advice to other nurses working with patients
16
4
5
4.94
0.25
All community clinical specialist nurses will engage in teaching staff who are working with patients and carers in their caseload
16
4
5
4.94
0.25
All community clinical specialist nurses will engage in teaching patients and carers within their specialist field
16
4
5
4.94
0.25
Table 2. Better care for individuals
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Background/role profile
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will develop criteria for appropriate referral into the service
16
4
5
4.75
0.45
All community clinical specialist nurses will work collaboratively with interprofessional team members
16
4
5
4.75
0.45
All community clinical specialist nurses will advocate for health and social services that best meet patient need
16
4
5
4.75
0.45
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RESEARCH
Table 3. Quality improvement Quality improvement
N
Minimum
Maximum
Mean
Standard deviation
All community clinical specialist nurses will measure improvements in quality and safety of patient care within their caseload
16
4
5
4.56
0.51
All community clinical specialist nurses will actively promote excellence in practice by sharing practice developments across the county
16
4
5
4.56
0.51
All community clinical specialist nurses will design and implement servicespecific evidence-based policies and practices
16
4
5
4.56
0.51
Mean
Standard deviation
Better health for populations
N
Minimum
Maximum
All community clinical specialist nurses will define their contribution towards enhancing the quality of life of the wider community through health promotion and education initiatives
16
4
5
4.69
0.48
A key role of all community clinical specialist nurses is to enhance the quality of life of the wider rural community through health promotion and education initiatives
16
4
5
4.69
0.48
A key role of all community clinical specialist nurses is to contribute toward enhancing the primary physical, functional and psychological wellbeing of individuals within their rural area
16
4
5
4.63
0.50
ing, whereas generic nurses are more likely to support an ongoing education and health maintenance programme. In a randomised controlled study of specialist nursing with renal patients, Wong et al (2010) used specialist nurses to make initial assessments, identify problems and set mutual goals and generic nurses for subsequent calls for health advice and reinforcement of behaviours and found that this model had an overall positive effect in the study group. These studies suggest that, while recognising the importance of health promotion in the role, some specialist nurses may find that they need to prioritise complex case management, drawing heavily on specialist knowledge and advanced clinical skills. However, the study by Proctor et al (2013) suggests that the development of nursing roles in integrated care systems is idiosyncratic and unsystematic. It is therefore possible that the specialist contribution to wider health promotion initiatives needs further systematic definition in conjunction with roles that other nurses and health professionals in the integrated rural team are undertaking.
Conclusion The Delphi technique enabled participants to identify the consensus view among specialist nurses regarding their unique nursing contribution within their rural community. Articulating the areas of strongest agreement and commonality of the specialist role is an important first step in enabling the specialist nurse group to gain consensus on priority areas for future measurement across the service. Having identified these, the next step for the team is to articulate these areas of consensus into a set of cross-service
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quality metrics that can then be tested and measured. Nurses must have responsibility for actions that lead to the outcome (in terms of legitimate authority, self-perception and sphere of practice) (Griffiths et al, 2008). The findings presented here highlight similarities to both Australian and Canadian models of care provision, in the sense that community clinical nurse specialists in the UK are required to undertake a role that includes clinical expertise, managing the care of complex populations, educating and supporting other interdisciplinary colleagues and influencing or facilitating change. Prior to this survey, the quality-care metrics available to nurses focused on acute, secondary care provision. The areas of consensus and shared practices unearthed by this Delphi survey go some way to articulating the real world of community clinical nurse specialists. This consensus highlights that specific quality indicators are required for such an important group of care providers. It is clear that more work is required to articulate relevant and appropriate specific and measurable outcomes for these indicators, which can then be tested further in rural and urban community settings. As a study design, the Delphi technique helps to empower expert practitioners to identify aspects of the role that are most amenable to measurement and then to consider ways in which other hidden aspects of the role could be made more visible. In reviewing and re-clarifying the role, the study design is inherently empowering. The clinical nurse specialists that participated in this study are able to articulate areas of strong consensus concerning their unique nursing contribution. The quality indicators identified by this group of nurses are amenable
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Table 4. Better health for populations
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RESEARCH to testing and may be significant to other nurse specialists, particularly those working in rural areas. BJCN
of health services in remote Scotland and Australia. Health and Place 16(6): 1136–44. doi: 10.1016/j.healthplace.2010.07.005 Proctor S, Wilson PM, Brooks F, Kendall S (2013) Success and failure in integrat-
Bryant-Lukosius D, Carter N, Kilpatrick K et al (2010) The clinical nurse specialist role in Canada. Nurs Leadersh 23: 140–66 Canales MK, Drevdahl DJ (2014) Community/public health nursing: is there a future for the speciality? Nurs Outlook, in press. Epub ahead of print 7 July. doi: 10.1016/j.outlook.2014.06.007 Community Nursing Research Strategy for Wales (2013) Community Nursing Research Strategy for Wales: executive summary. Workshop presented at Holiday Inn, Cardiff, 21 March. http://tinyurl.com/nro6an9 (accessed 22 October 2014) Davies P, Deaville J, Randall-Smith J (2008) Health in rural Wales: a research report to support the development of the Rural Health Plan for Wales. Institute for Rural Health, Final Report. http://tinyurl.com/npdkmb8 (accessed 22 October 2014) Gray C, Hogg R, Kennedy C (2011) Professional boundary work in the face of change to generalist working in community nursing in Scotland. J Adv Nursing 67(8): 1695–1704 Griffiths P, Jones S, Maben J, Murrells T (2008) State of the Art Metrics for Nursing: A Rapid Appraisal. National Nursing Research Unit, Kings College, University of London. http://tinyurl.com/beu3twk (accessed 22 October 2014) Hegney D, McCarthy A (2000) Job satisfaction and nurses in rural Australia. J Nurs Admin 30(7/8): 347–50 Hounsgaard L, Jensen AB, Wilche JP, Dolmer I (2013) The nature of nursing practice in rural and remote areas of Greenland. Int J Circumpolar Health 72: 20964. doi.org/10.3402/ijch.v72i0.20964 Hunsberger M, Baumann A, Blythe J, Crea M (2009) Sustaining the rural workforce: nursing perspectives on worklife challenges. J Rural Health 25(1): 17–25. doi: 10.1111/j.1748-0361.2009.00194.x Irvine F (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique. J Clin Nursing 14(8): 965–75. doi: 10.1111/j.1365-2702.2005.01193.x Lee HJ, Winters CA (2004) Testing rural nursing theory: perceptions and needs of service providers. J Rural Nurs Health Care 4(1): 51–63 Linstone HA, Turoff M, eds (2002) The Delphi Method:Techniques and Applications. Addison Wesley, Reading Maben J, Morrow E, Ball J, Robert G, Griffiths P (2012) High-quality Metrics for Nursing Care. National Nursing Research Unit. King’s College London. http://tinyurl.com/pm4c79b (accessed 22 October 2014) McMaster University (2012) The Clinical Nurse Specialist: Getting a Good Return on Healthcare Investment. http://tinyurl.com/neqq4vu (accessed 22 October 2014) Office for National Statistics (2004) Rural–urban classification. Department for Environment, Food & Rural Affairs. http://tinyurl.com/q8x98y6 (accessed 22 October 2014) Prior M, Farmer J, Godden DJ,Taylor J (2010) More than health: the added value
ed models of nursing for long-term conditions: multiple case studies of whole systems. Int J Nurs Stud 50: 632–43. doi: 10.1016/j.ijnurstu.2012.10.007 Queen’s Nursing Institute (2014) 2020 Vision: 5 Years On: Reassessing the Future of District Nursing. http://tinyurl.com/q8x98y6 (accessed 22 October 2014) Rowe G, Wright G (2001) Expert opinions in forecasting: role of the Delphi technique. In: Armstrong JS. ed, Principles of Forecasting: A Handbook for Researchers and Practitioners. Springer Science, New York Welsh Assembly Government (2010) Setting the Direction: Primary and Community Services Strategic Delivery Programme. Welsh Assembly Government, Cardiff. http://tinyurl.com/njrmn8w (accessed 22 October 2014) Wilson PM, Brooks F, Proctor S, Kendall S (2012) The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from a multiple case study design in England and Wales. Int J Nurs Stud 49: 2–14. doi: 10.1016/j.ijnurstu.2011.10.023 Wong FKY, Chow SKY, Chan TMF (2010) Evaluation of a nurse-led disease management programme for chronic kidney disease: a randomized controlled trial. Int J Nurs Stud 47(3): 268–78. doi: 10.1016/j.ijnurstu.2009.07.001
KEY POINTS w Clinical and teaching expertise was deemed to be most important for the clinical specialist nurses involved in the study
w The research indicates that the role of clinical specialist nurses working in rural Wales is similar to that in other countries in terms of the requirement to provide clinical expertise, education and ability to influence change
w Agreed definitions of community clinical nurse specialists are required
Support and care for patients with long-term conditions Helen McVeigh
About the book
§ Each chapter presents learning points, using a reflective approach
Like other books in this series, Fundamental Aspects of Long-Term Conditions provides a succinct, useful basis from which both student nurses and adult nurses can extend their knowledge and skills.
§ Essential guide to long-term conditions, exploring the key principles of About the author
practice, skills and policy
Helen McVeigh is a Senior Lecturer in Primary Care at De Montfort University Leicester. She is a qualified District Nurse. She has over 20 years experience of working in Primary Care working in both rural and inner city practices.
Other titles in the Fundamental Aspects of Nursing series: Children & Young Peoples Nursing Procedures Community Nursing Complementary therapies Finding Information Mental Health Nursing
Nursing Adults with Respiratory Disorders Nursing the Acutely Ill Adult Pain Assessment & Management Palliative Care Nursing 2nd edition Research for Nurses
Editor: John Fowler ISBN-13: 978-1-85642-392-2; 234 x 156 mm; paperback; 280Seriespages; publication 2010; £24.99
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Long-Term Conditions Edited by Helen McVeigh
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§ Case history examples included to illustrate issues discussed
Fundamental Aspects of
Fundamental Aspects of Long-Term Conditions
Providing support and care for individuals with a long-term condition is an essential feature of modern health care. Over 15 million people in England currently have a long-term condition, and it is predicted that these numbers will continue to rise. Treating the range of long-term conditions that affect the population will therefore play an important role for health professionals. This book is an essential guide to long-term conditions, exploring the key principles of practice, skills and policy. The chapters in this book can be read as stand-alone chapters, or the book can be read in sequence. Full references are provided.
Fundamental Aspects of Nursing series
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h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 6, 2015. For personal use only. No other uses without permission. . All rights res 18/1/10 12:38:13
