Continuing their overarching theme ‘Our Nurses. Our Future’, the International Council of Nurses (ICN) has chosen to focus International Nurses Day 2024 on the economic power of care hoping to reshape perceptions and demonstrate how strategic investment in nursing can bring economic and societal benefits.
This builds on the ICN Charter for Change report launched on International Nurses Day 2023 which set out a series of commitments for governments and policy makers. QNIS has invited its Fellows to reflect on these policy actions and share their thoughts about the economic power of community nursing care.
The next blog in this series comes from Dr Caroline Dickson, QNIS Fellow, Senior Lecturer/Researcher at Queen Margaret University. In this blog, Caroline is focusing on policy action number six which states:
“Enable nurses to work to their full scope of nursing practice by strengthening and modernising regulation and investing in advanced nursing practice and nurse-led models of care. Reorientate and integrate health systems to public health, primary care health promotion and prevention, community, home-based and person-centred care.”
#IND2024
#OurNursesOurFuture
The economic impact of community nurses is significant but more attention needs to be given to creating cultures to support community nurses in their wellbeing and development for this to be fully realised. Rhetoric in the UK for the last 20 years at least has been that we need to shift care into the community. To date, the resources haven’t really followed. This is evident in for example, the falling number of GPs and continued and heavy investment in the acute sector, putting community nursing in a really challenging position. Personally, I don’t think community nurses are being used to their optimum. They are trying very hard, but I think there are barriers that prevent them from making the most economic impact and impact for people in our communities. For example community nurses are working in a context that has not changed much, in terms of knowledge of and respect for nursing in the community. Community nursing leadership has still to ‘grasp the nettle’ in terms of transforming the community nursing workforce into a dynamic service that is adequately resourced with workplaces that are good places to work. At point of care, community nurses have the confidence and competence to lead teams effectively and make a difference every day to people on their caseload and in their communities. However, often conditions are not created to give that voice.
It does seem the tide may at last be turning. There now seems to be more of a commitment on trying to shift resources into community and primary care and the rise in third sector organisations in recent times has been mammoth. The Queens Nursing Institute Scotland and its sister organisation, the Queens Nursing Institute is influencing community nursing across a broad range of specialisms and contexts. I think community nursing is doing its level best to meet the Scottish Government’s commitment of keeping people in their homes or in homely settings and trying to avoid unnecessary hospital admissions. This is evident in the continued development of their knowledge and skills, particularly around the more technical aspects of nursing. Advanced clinical assessment and prescribing practice is making an impact on patient outcomes but more needs to be done in developing leadership at every level of community nursing to ensure these skills are being used to best effect and community nursings’ public health commitment is honoured.
Public health, of course, has a huge role to play in community care. However, public health today is very much reliant on the third sector, whereas district nursing (my background), and health visiting used to be key public health roles, in terms of caring for ‘the sick poor’, addressing inequalities of health and being social reformers. But that aspect of the role seems to have been lost to the much more technical aspects. Also, community nursing teams are overloaded and, in many cases, feeling overwhelmed because of current problems in recruitment and retention. They may consider they have little time to be social reformers but, being experts in their communities, they are in a great position to signpost people receiving their care to other services that best meets their needs. There are some wonderful examples of community nurses who are engaging with and collaborating with third sector organisations and leaders should continue to be encouraging and supportive of this type of collaboration. Investment to support collaboration with care homes in particular should be supported, as there is real potential for community nurses to make a huge impact in this area.
The very essence of nursing is caring, and I feel that sometimes as a society we don’t always place the value on caring anymore, and that is unacceptable.
Change will only happen if the community nursing voice is used and heard. What I’d like to see is community nurses advocating for themselves more. I have always fostered this aspect of leadership in the programmes that I have led at Queen Margaret University in Edinburgh, but organisational culture has a pivotal role in this. More needs to be done within health and social care to encourage community nurses to use their voice and to create platforms for community nurses, so they are heard; so that they can confidently advocate for patients, families, the profession, and themselves. Community nurses need to be at the right tables, at the right time, to engage in dialogue about the issues that matter. Meetings, from team meetings, cluster meetings to strategic meetings, they should be more about dialogue and sense-making than purely information dissemination. Community nurses at every level should have a greater role in clinical decision making. They should be encouraged to share their skills and knowledge with colleagues so that they advocate for the best possible care and outcomes.
In recent years there has been significant investment in education from Scottish Government, to help develop community nurses and give them a clear career path, which has been very welcome. It is vital that community nurses are encouraged to develop and build their skills, but in addition to the focus on public health perspectives, I’d like the balance of leadership and technical skill re-addressed. I have always considered the SPQ programmes, the Specialist Community and Public Health Nursing programmes, to be leadership development programmes. Following the significant investment made in terms of university places, it is important that community nurses are supported to demonstrate that leadership beyond managing their team and their caseloads. Again, I think it comes down to culture. We need to create cultures that enable community nurses to exercise their leadership. A movement from the predominance of management, and transactional leadership to more person-centred and transformational leadership will help community nurses reach their potential, be the leaders that they are capable of being and be the advocates that will make a difference to people receiving care.
We do however need to care about the wellbeing of the community nursing workforce. Nurses and other healthcare professionals and support staff are enduring levels of pressure that are unprecedented. Everyone is doing their best and support for their wellbeing is crucial. Adopting the values of person-centredness with staff in the same way we do to patients, will ensure those providing care are afforded the same consideration and support as people receiving care. It is vital to develop effective workplace cultures where people are able to self-nourish. I am passionate about developing such cultures and that is why my colleague and friend, Kath MacDonald and I co-developed the CAKE resource with community nursing colleagues.
It is increasingly recognised that patient care is impacted on when staff are burnt out and they don’t have time to reflect on their practice. When staff are under so much pressure, everybody feels undervalued. The CAKE resource aims to improve team wellbeing and effectiveness. Everybody in teams is encouraged to respect not only their own needs, but the teams’ collective needs and to consider how they support each other in meeting those. It is important that these are embedded into everyday practice because work should not have a negative impact on personal lives and self-care needs to be continuous and sustainable.
At Queen Margaret University we have been influencing this transformation in a number of ways. Our ethos been person centeredness and respect for personhood and our curricula are scaffolded in the person-centred curriculum framework.
The team and I have encouraged (and still do) a more facilitative and relational approach to leadership. We help the students to understand who they are as people, their uniqueness and their values. They are encouraged to understand what their values are and be able to articulate them. This is something most people find challenging. It does take quite a bit of introspection to work out. We encourage students to use those values as a moral compass, to help them navigate the complexities of practice. We encourage them to facilitate shared ways of working in their team by identifying the team’s values and what that means for them in practice. These can then be used to create a shared vision of the team they wish to be. We also support students to observe practice to identify what’s working well and what’s working less well and taking that into a dialogue with the team, giving a much more person-centred approach to leadership. According to students, the impact of this is increased resilience for them and their teams, helping them to share decision-making and adopt a solution-finding approach. This approach is respectful, and collaborative. It is more about shared responsibility than perhaps than our curricular approach previously.
We are also influencing this transition by encouraging undergraduate students to consider the option of community (including care home nursing) as a positive career choice. In recent years there has been an increase in recruitment to the QMU undergraduate programme of colleagues who have either community or care home experience. It is important that universities pay attention to this when recruiting educators from diverse backgrounds. It is then up to these educators to be able to advocate for their specialism, bringing their knowledge and expertise to the curriculum and to the students’ learning experiences. One area that has been neglected is care home nursing. I developed the curriculum for the Postgraduate Diploma: Advancing Care Home Nursing (Person-centred Practice) during the pandemic and when I was doing the market research I became really passionate about the importance of making care home nursing a positive career choice. Care homes need to be seen as a positive societal choice. The very essence of nursing is caring, and I feel that sometimes as a society we don’t always place the value on caring anymore, and that is unacceptable.
Enhancing the impact of community nursing economically and on patient care and outcomes, needs enhanced support and expectation of leadership across the service. It also needs prioritising the wellbeing of the workforce and collectively supporting and advocating for ongoing education and development. This transformation will paradoxically help us to return to the very essence of community nursing which is caring, reducing inequalities in health and being social reformers.
