An evaluation of the Community Nurse Consultant Pilot Project in an NHS Health Board in Scotland

McMillan Rome

Social research and training consultants

An evaluation of the

Community Nurse Consultant Pilot Project

in an NHS Health Board in Scotland

An evaluation of the impact of the Community Nurse Consultant Pilot Project

Page 2 of 21 McMillan Rome


Report authors

Andrew Rome, McMillan Rome Ltd

Professor Lawrie Elliott, Edinburgh Napier University

Professor Catriona Kennedy, Edinburgh Napier University/University of Limerick

Dr Margaret Currie, The James Hutton Institute

Alison Rome, McMillan Rome Ltd

Correspondence to:

Andrew Rome

Director

McMillan Rome Ltd

33 Strathmartine Road

Dundee, DD3 7RW

Tel. 07789 393864

Email: [email protected]

Website: www.mcmillanrome.co.uk

mailto:[email protected]

http://www.mcmillanrome.co.uk/




Table of Contents

EXECUTIVE SUMMARY ..................................................................................................... 5

CHAPTER 1: INTRODUCTION ........................................................................................... 6

1.1 AIMS AND FOCUS ........................................................................................................................................... 6

1.2 DESIGN AND METHODS ................................................................................................................................. 6

1.2.1 Scope of study ....................................................................................................................................... 6

1.2.2 Methods ................................................................................................................................................. 7

1.3 PROJECT GOVERNANCE ................................................................................................................................. 7

1.4 ANALYSIS...................................................................................................................................................... 7

CHAPTER 2: RESULTS - STRUCTURES AND SUPPORT SYSTEMS ......................... 9

2.1 SUPPORT STRUCTURES .................................................................................................................................. 9

2.1.1 Internal supports and infrastructure ..................................................................................................... 9

2.1.2 External supports ................................................................................................................................ 10

2.2 KEY RELATIONSHIPS AND ELEMENTS OF THE POST ...................................................................................... 10

2.2.1 Response of Colleagues ...................................................................................................................... 11

CHAPTER 3: RESULTS - IMPACT OF COMMUNITY NURSE CONSULTANT

POST ....................................................................................................................................... 13

3.1 PROMOTING HEALTH AND SELF-CARE ........................................................................................................ 13

3.1.1 Utilising tele-care and telehealth ........................................................................................................ 13

3.1.2 Promoting health and addressing inequalities .................................................................................... 13

3.1.3 Enabling and supporting self-care ...................................................................................................... 14

3.2 DEVELOPING SYSTEMS OF CARE ................................................................................................................. 14

3.3 WORKFORCE DEVELOPMENT ...................................................................................................................... 15

3.3.1 Building workforce capacity and capability ....................................................................................... 15

3.3.2 Strengthening leadership and team working ....................................................................................... 16

3.3.3 Achieving an outcome-focused approach ........................................................................................... 17

3.4 WORKING WITH OTHERS ............................................................................................................................. 17

3.4.1 Working with other agencies and disciplines as partners ................................................................... 17

3.4.2 Working with clients, carers and patients as partners ........................................................................ 18

CHAPTER 4: DISCUSSION ................................................................................................ 19

4.1 FRAMING THE RESULTS ............................................................................................................................... 19

4.1.1 Professional impact ............................................................................................................................ 19

4.1.2 Clinical impact .................................................................................................................................... 20

4.2 BARRIERS .................................................................................................................................................... 20




4.3 FUTURE DIRECTION ..................................................................................................................................... 20

Table of Figures

Table 1: Thematic grouping of MNIC elements ..................................................................................................... 8

Chart 1: Organisational relationships of Community Nurse Consultant post ......................................................... 9




Executive Summary

The role of Community Nurse Consultant (CNC) was developed by the Queen’s Nursing

Institute Scotland (QNIS) in collaboration with an NHS Health Board in Scotland (The health

board). The post was funded for two years (starting 2011) to commemorate the 150th

anniversary of district nursing.

The aim of the evaluation was to capture the impact of the CNC in regard to the

Modernisation of Nursing in the Community1 and community nursing care for older people

living in their own homes in the Health Board area.

This was a retrospective evaluation that drew upon information and opinion from a range of

stakeholders and the post holder using semi-structure interviews and written documentation

(e.g. job description, minutes of meetings and policy documents). The stakeholders had

worked with the post holder in some capacity and included managers and practitioners within

the health board and from a variety of organisations including local authorities, Scottish

Government, residential care homes and Higher Education Institutions. These were identified

in consultation with the post holder and their line manager, and a final list of 21 individuals

was approved by the contract manager at QNIS.

The data were analysed using the twelve elements contained within the Modernising Nursing

in the Community framework.2

Given the scope of our evaluation it is not possible to determine whether the work of the post

holder led directly to improved outcomes for patients, but it is evident that he/she contributed

visibly to strategic development of the community nursing and provided leadership in the

development of some community-based services for older people in the community. There

was also evidence the post was instrumental in developing partnerships between parts of the

NHS and external organisations.

Some environmental factors facilitated the work of the post holder, notably the support from

senior managers and external organisations and the buy-in from health professionals to the

training and professional development opportunities develop by the post holder. Barriers

included the initial lack of strategic and operational vision (including concerns expressed by

colleagues) during the initial introductory phase of the post and the apparent confused lines of

communication and management. The post also appeared to lack administrative support.

The piloting of a Community Nurse Consultant post has allowed the QNIS and the health

board to evaluate the initial introductory phase of the role. Going forward, there are a number

of issues highlighted through this evaluation which, if addressed, could enhance and support

similar posts.

1 Modernising Nursing in the Community (2012). Available at http://www.scotland.gov.uk/Resource/0039/00396734.pdf

2 Ibid

http://www.scotland.gov.uk/Resource/0039/00396734.pdf




Chapter 1: Introduction

The role of Community Nurse Consultant (CNC) was developed by the Queen’s Nursing

Institute Scotland (QNIS) in collaboration with an NHS Health Board in Scotland (the health

board). The post was funded for two years (starting 2011) to commemorate the 150th

anniversary of district nursing.

1.1 Aims and focus

The aim of the evaluation is to capture the impact of the CNC in regard to the Modernisation

of Nursing in the Community3 and community nursing care for older people living in their

own homes in the health board area.

From the evidence collected, the evaluation team makes recommendations for the future

development of the CNC role at national and Health Board level.

1.2 Design and Methods

1.2.1 Scope of study

Our methodology is influenced by the work of Gerrish et al4, in terms of the literature review

on the evaluation of Nurse Consultant roles5 and also in the utilisation of their toolkit that was

developed in 20116.

The literature review identified a number of key issues:

It can take up to 5 years for a post to develop fully7

The impact is multi-faceted and hard to capture. For example, Nurse Consultants often

work with others to influence practice8

Previous studies identify perceived (self reported) impact rather than actual (observable)

impact9

3 Ibid

4 Gerrish K., Guillaume L., Kirshbaum M., McDonnell A., Nolan M., Read S. & Tod A. (2007) Empowering Front-Line Staff to Deliver

Evidence-Based Care: The Contribution of Nurses in Advanced Practice Roles. Sheffield Hallam University, Sheffield.

5 Kennedy F, McDonnell A, Gerrish K., Howarth A, Pollard C. & Redman J. (2012) Evaluation of the impact of Nurse Consultant roles in

the United Kingdom: a mixed method systematic literature review. Journal of Advanced Nursing 68(4), 721–742.

6 Gerrish K, McDonnell A, & Kennedy F. (2011) Capturing Impact: A practical toolkit for Nurse Consultants (Sheffield University)

7 National Nursing Research Unit (2007) Advanced Nursing Roles: Survival of the Fittest? Policy plus evidence, issues and options in health

care, Issue 6, National Nursing Research Unit, King’s College London, London.

8 Op. cit. Gerrish (2007)

9 Humphreys A., Johnson S., Richardson J., Stenhouse E. & Watkins M. (2007) A systematic review and meta-synthesis: evaluating the

effectiveness of nurse, midwife/allied health professional consultants. Journal of Clinical Nursing 16(10), 1792–1808.




The evaluation also takes cognisance of the findings of the critique of new community

nursing roles conducted by Aranda and Jones which identified political, structural and

personal challenges in establishing such roles.10

Thus, given the scope of the current

evaluation it is not possible to examine the political drivers which shape the new role.

1.2.2 Methods

This was a retrospective evaluation that drew upon information and opinion from a range of

stakeholders and the post holder using semi-structure interviews and written documentation

(e.g. job description, minutes of meetings and policy documents). The stakeholders had

worked with the post holder in some capacity and included managers and practitioners within

the health board and from a variety of organisations including local authorities, Scottish

Government, residential care homes and Higher Education Institutions. These were identified

in consultation with the post holder and their line manager, and a final list of 21 individuals

was approved by the contract manager at QNIS.

Interview data were collected using a digital voice recorder and transferred onto an encrypted

hard drive. All files were transcribed in-house and stored within the same hard drive. No third

party had access to the data at any point of collection, storage or analysis. Data will be stored

on an encrypted hard drive for 5 years after which time it will be destroyed.

1.3 Project Governance

An application was made to the Head of Research, Development and Evaluation at the health

board in October 2012. The submission included all arrangements relating to accessing

participants, both professional and lay, gaining informed consent, and the intended data

collection tools. Written permission was granted on 7th

November 2012 and accompanied by

a letter of access to conduct the evaluation.

Permission to use the data gathering tools contained within ‘Capturing Impact: A practical

toolkit for Nurse Consultants’ was sought from the lead author Professor Kate Gerrish. This

was obtained by email on 01/02/2013.

1.4 Analysis

The data were analysed using the twelve elements contained within the Modernising Nursing

in the Community framework.11 These are thematically grouped under 4 global topics as set

out in Table 1 below.

10 Aranda J and Jones A (2008) Exploring new advanced practice roles in community nursing: a critique. Nursing Inquiry 15,

1, 3-10.

11 Op. cit. Modernising Nursing in the Community




Table 1: Thematic grouping of MNIC elements

Global Topics MNIC Elements

Promoting Health and Self-Care Utilising telecare and telehealth

Promoting health and addressing inequalities

Enabling and supporting self-care

Developing Systems of Care Providing choice and care in the right settings

Using care pathways

Anticipating health needs and responding earlier

Improving quality and efficiency

Workforce Development Building workforce capacity and capability

Strengthening leadership and team working

Achieving an outcome-focussed approach

Working with Others Working with other agencies and disciplines as partners

Working with clients, carers and patients as partners

The evaluation also sought to consider the potential impact of the post on community care for

older people living in their homes and the context in which the post operated.




Chapter 2: Results - Structures and Support Systems

The post holder commenced work in January 2011, and moved to part-time (0.5WTE)

working in May 2012. The job purpose, as identified in the description, was to “Improve

outcomes for patients by providing strong, strategic, clinical and professional nursing

leadership to primary care and community services within [the Health Board].”12

2.1 Support structures

The post required to have clearly delineated clinical and managerial relationships and support

structures. This would provide the post holder, the managers and senior clinicians, and the

district nursing workforce with a clear sense of role and responsibility within what was a

changing landscape. Evidence was sought from stakeholders, written documentation and the

post holder, and is described here in terms of internal supports and external supports.

2.1.1 Internal supports and infrastructure

Community nursing services within the health board area are structured under three clinical

directorates. These are Primary Care and Mental Health Services (PCMHS), Integrated Care

and Partner Services (ICPS) and Integrated Care and Emergency Services (ICES).

Chart 1: Organisational relationships of Community Nurse Consultant post13

12 Nurse Consultant (Community Nursing Adults) Job Description (Draft) An NHS Health Board in Scotland (Undated)

13 Adapted from an NHS Health Board in Scotland Organisational Chart and Community Nurse Consultant Job Description




This arrangement differs from that in other health boards where they would normally be

housed within Community Health Partnerships (CHP) or similar structures14

. In this health

board CHPs are described as being planning structures.

Chart 1 sets out the key relationships of the CNC, in terms of lines of line management and

professional accountability (solid lines) and close working relationships (dotted lines).

The management of the community nursing services sits within Integrated Care and Partner

Services. This includes District Nurses, District Midwives, along with surgical and some in-

patient staff. Professional leadership for these staff is provided by the Associate Nurse

Director (AND) from the Primary Care and Mental Health Services Directorate. This

arrangement was described by stakeholders within the health board as being, ‘A bit weird and

wonderful’ (Manager 1) and, ‘It’s difficult and challenging when I think about the way in

which the services are set up, the way in which the Directorates are set up…’ (Manager 3). In

relation to the cross-cutting nature of community care, ‘It can be quite messy because we’ve

got a number of managers involved’ (Manager 1).

The AND for Primary Care and Mental Health Services has a remit to provide professional

leadership and to modernise the service and therefore ‘Sits to one side of the directorate that

manages the [ICPS] service’ (Manager 1). For this reason, and that the AND was previously

a Nurse Consultant and could provide an understanding to the breadth of the role, the new

post of Community Nurse Consultant was housed within the PCMHS directorate, rather than

ICPS which contains the rest of the District Nursing Services.

2.1.2 External supports

The original aim was to provide academic support to the post holder which enabled the

design and delivery of education and training packages to post-graduate students. This

arrangement failed to materialise for a number of reasons, including the initial absence of the

post holder for several weeks due to compassionate leave and that the nature of the teaching

that was available was out with the post holder’s area of expertise.

It is worthy of note that QNIS provided on-going support to the post holder, in terms of

adopting a flexible approach to the way in which the post evolved and, ultimately ensuring its

continuation when it may otherwise have been halted.

2.2 Key relationships and elements of the post

The primary relationship of the CNC post was between the AND for PC&MH services, who

provided the strategic lead for community nursing (Chart 1). The alignment of this post with

the AND was purposeful, for the reasons set out earlier, and the relationship has been

productive in terms of facilitating the introduction of new ways of delivering nursing care in

the community. However this post holder’s involvement in these activities detracted from the

14 Watt G, Ibe O, McLelland N. Study of Community Health Partnerships. Scottish Government Social Research (2010)




development of relationships between the CNC and the Community Nurse Managers and

wider district nursing workforce who were housed within a parallel management structure.

These had all been identified in the post holder’s job description as being ‘Close working

relationships’.

The work on developing telehealth15

services in the health board has manifested in the

creation of one Community Ward in each of the three local authority areas. Community

Wards are based on the principle of Virtual Wards16

previously implemented in areas of

England e.g. Croydon17

. Each of these Community Wards employed an Advanced Nurse

Practitioner (ANP). The post holder was responsible for the development of a core

competency framework specifically designed to ensure that the staff recruited to these posts

had the knowledge, skills and experience required to deliver care.

Developmentally, this has been the largest single project the CNC was involved in and he/she

provided strong leadership and direction to this new service and to the three ANPs working

within it. More specifically, the post holder was instrumental in organising education,

training and service development for these three practitioners.

2.2.1 Response of Colleagues

As has been noted elsewhere18

there was evidence that the arrangements for responsibility

and accountability were not universally understood by the stakeholders. Specifically there

was a lack of clarity around how the CNC post related to other clinical and managerial posts

within the three-directorate structure.

‘From quite senior nurses to frontline practitioners they have not welcomed the post. They’ve

believed it was unnecessary. So that was something, in terms of that difficulty in bringing in

new roles’ (Manager 2).

‘I think some of these challenges were because of some management resistance within the

community nursing side of things which made that role more challenging. I think if there had

been a better collaborative approach, I think we could have moved things along a lot faster’

(Manager 4).

There were also concerns raised about the ‘lack of vision and lack of leadership’ regarding

the way this post was introduced. This was described by one stakeholder as being, ‘Typical of

[the health board], appoint someone first then get them to write their own job description’

(Practitioner 9).

15 Telehealth is an approach to healthcare delivery that is tailored to an individual’s needs.

16 A Virtual Ward provides the security and the benefits of multi-disciplinary team working associated with hospital wards

for patients living at home. Patients requiring complex disease management are enabled to remain in their own home through

active, intensive monitoring of their physical condition, treatment review and support.

17 Similar facilities are now also in existence in other Scottish Health Board areas

18 Bonsall K. & Cheater F. (2008) What is the impact of advanced primary care nursing roles on patients, nurses and their

colleagues? A literature review. International Journal of Nursing Studies 45, 1090–1102.




During the initial months of the pilot the lack of clarity regarding management roles and

structures could have been destabilising for the post holder, who had not previously worked

in the health board area. At that time the post holder benefitted from the support of the

Clinical Improvement Manager who also had a remit to develop services relating to primary

care, such as the ‘Living and Dying Well’ project. The Clinical Improvement Manager was

able to assign staff to assist the CNC with this work as well as helping to orientate and advise

the post holder with regard to the many groups and committees that the CNC was invited to

attend.

‘When [the post holder] was doing some piece of work in the Living and Dying Well in the

Community two of my staff that supported that project work as well. So it’s almost like a kind

of negotiation to help her achieve her goals.’ (Manager)

There is documentary evidence which details the discussions between QNIS and the health

board with regard to the joint funding arrangements over the two year pilot period. However

this did not include administrative support. Many stakeholders felt this was to detriment of

the efficiency of the role and to the working arrangements of the individual. This was in

contrast to the position which existed in relation to the three Nurse Consultants with whom

the post holder was co-located. These hospital-based posts, which preceded the Community

Nurse Consultant post, all had administrative support.




Chapter 3: Results - Impact of Community Nurse Consultant post

3.1 Promoting Health and Self-Care

The CNC had no direct clinical input which differs from the other Nurse Consultant posts in

the health board area and nationally where up to 50% of the post is clinical19

. Although a

recent development has been the allocation of one session per week to work directly with

patients and to support frontline staff in the clinical environment. This said it was clear, that

the post holder worked strategically to influence the practice of others during the pilot period.

3.1.1 Utilising tele-care and telehealth

The post holder chaired a short-life Telehealth working group in 2012 in response to a

request of Scottish Government and QNIS to deliver presentations across Scotland on the

programmes of work related to telehealth and tele-care20

in the health board area.

The objective of the working group was to undertake an evaluation particularly related to

improvements in the quality of care in patients with Long Term Conditions (LTCs) who are

supported by health professional and telehealth equipment in their home. The development of

these initiatives in the health board had been led by a District Nursing Team Leader. The role

of the post holder was to review its progress to date and contribute to the QNIS workshops.

3.1.2 Promoting health and addressing inequalities

An NHS Health Board in Scotland is co-terminus with the three Local Authorities. These

areas have distinctly different socio-economic demographics, with one having a higher

burden of deprivation-related problems.

‘We are one of the highest areas [of social and economic deprivation] in Scotland’

(Practitioner 2).

The three Community Wards and the ANPs that were managed by the post holder were

located within each of these areas. While it is too early to measure impact, it is anticipated

that, as well as the clinical benefits of preventative healthcare, there will be a socio-economic

benefit to patients and carers who live in the more remote and rural parts of the area in terms

of reduced travel time and costs in accessing the Community Wards compared to hospital-

based care.

19 Kennedy op. cit. p1

20 Tele-care – a range of alarms and sensors in the home to enable independent living and linked to a call centre.




3.1.3 Enabling and supporting self-care

The post holder played a lead role in the development and implementation of the Community

Wards in the health board area.

This work was overseen by two groups; the Community Wards Clinical Governance

Committee 2, which the post holder co-chaired, and the Community Wards Steering Group.

These groups ran concurrently and met on a two-monthly basis.

The Community Wards Clinical Governance Committee 2 was responsible for overseeing the

development of guidelines, protocols and standard operating procedures and the Steering

Group developed the business case for the initiative, managed the recruitment of the ANPs

and led the development of the competency framework.

‘I think it [Community Wards] might have been set up, but I don’t think the three Advanced

Nurse Practitioners would be performing at the level they are performing at if it hadn’t been

for this post’ (Manager 5).

3.2 Developing Systems of Care

The consensus view of stakeholders was that the post had either led or had contributed

greatly to the planning and delivery of initiatives such as the Anticipatory Care Pathways and

Living & Dying Well and that without this post being in place these would either be at an

earlier stage of development or still in the planning stages. Thus the post was integral to the

success of these initiatives.

The post holder worked with a range of NHS and external colleagues to develop ways of

delivering care in the community in a consistent, auditable and evidence-based way. This

manifested in the development of care pathways to ensure that decisions which affect the way

in which people are cared for and the choices that people make regarding terminal care are

based on patient choice and best practice.

‘I think when it came to the nitty gritty regarding the care and the level of knowledge and

competency of the staff required, then the professional aspect of it in relation to the nursing

staff was very much led by this post’ (Manager 5).

The post holder’s leadership and contribution to the work on ‘Anticipatory Care’ and ‘Living

and Dying Well’ has resulted in people being able to stay in their own homes through the use

of telecare technologies, or continue to reside in Care Homes where otherwise they may have

had to be treated in hospital.

‘There is a growing reduction now in the amount of unplanned admissions to hospital

settings from Care Homes [as a result of the Anticipatory care pathway]’ (External

Stakeholder 5).

‘I think if you took the post out of the equation then…we’d have less well developed and less

well-informed advanced anticipatory care plans' (Manager 1).




The post holder was also a member of the Significant Event Analysis Review Group as an

expert for care of the acutely unwell patient in the community. The remit of this group was to

undertake a root cause analysis of clinical events. The output of this work was the completion

of a robust and detailed process to identify root cause, the development and submission of a

report including recommendations to senior personnel and other key stakeholders.

3.3 Workforce Development

3.3.1 Building workforce capacity and capability

Over the two-year period there was a significant investment by the post holder in developing

competency frameworks, initially for the post of Advanced Nurse Practitioner. But also

latterly looking at what knowledge and skills other community-based nursing staff need in

order to carry out an increasing range of technical procedures previously undertaken in

hospital.

‘I’m pretty confident that [the post holder’s] position has been in the background driving

various things. As an example, assistance for nurses in care homes to train them up with a

McKinley T34 syringe pump driver and things like that. I’m pretty certain her role has

assisted, if not led the improvements as far as that’s concerned’ (External Stakeholder 5).

The post holder chaired the Task & Finish Group, a multi-disciplinary working group with

the remit to take forward, at local level, recommendations outlined in national strategic

documents such as ‘Living and Dying Well’ and ‘Building on Progress’ documents.

The objectives of the Group were to improve the quality of care to patients receiving

palliative and end of life care within a pilot area with a specific plan to roll out Education and

Training on Advanced Anticipatory Care Planning to key professionals across Acute and

primary care Nursing, Care Homes and GPs, and to reduce avoidable hospital admissions.

‘One of the things that obviously the post holder has been involved in there is the Task and

Finish Group that has been set up there with a particular remit…looking in to the End of Life

and bereavement and palliative care. So that sub-group has come to an end but it has come

to an end very, very successfully…what we are aware of is that there was a big part played in

setting that up and that’s led to a significant joint training exercise that’s going on between

NHS and Social Services’ (External Stakeholder 4).

‘[The post holder] had actually set up the sub-group out of that for that End of Life training.

And as I say now we are offering twenty courses a year between health, social work, older

people services and the private sector and the voluntary sector. So there is quite a

widespread benefit of that having taken place’ (External Stakeholder 4).

Given the problems in linking with the local university the post holder developed links with

colleagues in other Higher Education Institutions, with the aim of developing the

Competency Framework for the Advanced Nurse Practitioners based around the four pillars

of advanced practice; clinical practice, education, research and leadership. This allowed




participants to exit with a Postgraduate Degree in Advanced Nursing Practice or continue

towards an MSc. This work also considered the future educational needs of district nurses

and how best these can be delivered. In addition, the post holder also lent support to

individual nurses such as providing mentorship for a community nurse undertaking an MSc.

‘One of the things that we hadn’t really appreciated was in fact that the teaching element of

[the post holder’s] role would actually be done in a much different way. But in fact the

teaching that she would get involved in would be developing our nurses, the ANPs. So that’s

where the teaching element came in’ (External Stakeholder 1).

The creation of the Community Nurse Consultant role and its introduction at a time of change

and re-structuring within community nursing in the health board area has provided a clinical

career pathway that did not previously exist.

‘I think at the time that role was established there was a lot of uncertainty as to what that

role would achieve. But I think now that things are settled definitely people see the

progression structure. There is a change within; there is a Community Staff Nurse you can

become, there’s a Deputy Team Leader which would lead to a Team Leader, which then

could lead to the Nurse Consultant role. Whereas in community nursing before it was

community staff nurse, charge nurse that was it’ (Practitioner 6).

3.3.2 Strengthening leadership and team working

The introduction of a senior clinical nursing post in the community enabled the development

of services at a pace and direction that was not previously possible.

‘That role has been innovative in leading into places we haven’t gone before’ (Practitioner

6).

It has provided a focal point of change within community nursing and in its relationships with

other key stakeholders.

‘Unless you’ve got this type of role strategically placed in the various areas then the silos

will continue. They might reshape and reform in different ways but they’re will still be loss of

communications and private agendas going on and that’s not going to make things work. At

the end of the day we all know the socio-demographic and financial imperatives that we’ve

got to deal with. You need a role like this to help the catalyst continue to crack the situation…

a good example I would say is that there are various pieces of information gathering and I.T.

packages. But they don’t talk to each other and this type of role can bring the various groups

together to look at the commonalities so that you can get something in that union. You can

work out a system’ (External Stakeholder 5).

There was a consensus view from the stakeholders that the post holder provided clinical

leadership in the development and implementation of the 3 ANP posts within the Community

Wards and continues to provide on-going clinical support, albeit at a reduced level.

Inevitably, in directing a finite resource such as this post to these projects it is at the expense

of other activities which may also have benefitted from this level of clinical leadership. The




district nursing teams have undergone structural changes as well as a process of role re-

definition. It could be argued that the benefits accrued as a result of the resource attributed to

the Community Wards was at the expense of the clinical leadership of the 200 nurses within

the district nursing teams.

‘Some staff have met with [the post holder], others haven’t. So therefore they know what she

looks like. But as far as having any impact on their practice, no that would be wrong’

(Practitioner 2).

3.3.3 Achieving an outcome-focused approach

Although it is still very early to make causal links between the role of Community Nurse

Consultant and improvements in patient care there are indicators that the work undertaken by

the post holder is having a ‘knock-on effect’ through the improvements in the training of

staff.

‘[It is] very difficult to quantify in terms of what kind of difference it [the training set up by

the CNC] made to reshaping care and shifting the balance about keeping folk out of care

homes and in hospital. But the indication from the training itself was a very high return of

satisfaction from the staff that attended, and for them to go about their business in a much

more professional manner because of it. And again I’ve seen that evidence and I’ve seen that

evaluation from the hospice and the social work side of it. And they are feeling that that is

making a really big impact in the Services that provide it’ (External Stakeholder 4).

‘The End of Life training had been subject to a Change Fund bid. We are actually using the

logic model for the setting up of that. So it’s been recorded in the convalesce system about

the outcomes. So that’s been one of the outcomes that has performed really high’ (External

Stakeholder 4).

3.4 Working with Others

The CNC job description sets out the requirement for the post holder to work in partnership

with GPs, AHPs, nursing colleagues in acute settings, service managers and local

authorities.21

3.4.1 Working with other agencies and disciplines as partners

The Task & Finish Group has a membership list of 28 individuals, 12 of whom were from

outside the NHS. This included representatives from the residential care home sector, the

Care Home Partnership, who recognised the important role of the post holder in, ‘Breaking

down silos’ in order to improve communication and joint working across boundaries.

21 Nurse Consultant (Community Nursing Adults) Job Description (Draft) An NHS Health Board in Scotland (Undated)




‘For somebody working in the partnership and working like myself in the middle

management role, again it’s just about having one specific go-to person [the post holder].’

(External Stakeholder 4).

Through the work on Anticipatory Care Pathways and the Community Wards the post holder

worked with colleagues in the Clinical Improvement Team to engage with clinicians in

primary care and the acute hospitals to develop multi-disciplinary systems of working.

‘I would say that since [the post holder] has come into post one of the things that, as a nurse

working in the NHS for many years now, that we are a much closer partnership now with

private sector than we ever had before in my memory’ (Practitioner 5).

The post holder has also contributed to the development of community nursing at a national

level through membership of working groups such as the Modernising Community Nursing

Programme Board (Scottish Government), National Website Development Group (NES) and

the short-life national working group for the development of a District Nursing career

framework.

3.4.2 Working with clients, carers and patients as partners

Evidence from the post holder and the Patient & Public Involvement (PPI) Officers

confirmed that there has been no direct involvement with patients, clients and carers in the

design and delivery of these services. Participation has been limited to the production of

newsletters that are distributed to outlets where patients can access these.




Chapter 4: Discussion

The ultimate purpose of this role is to “Improve outcomes for patients by providing strong,

strategic, clinical and professional nursing leadership to primary care and community

services within [the health board area].”22

Given the scope of our evaluation it is not

possible to determine whether the work of the post holder lead directly to improved outcomes

for patients, but it is evident that he/she contributed visibly to strategic development of the

community nursing and provided leadership in the development of some community based

services for older people in the community. There was also evidence the post was

instrumental in developing partnerships between parts of the NHS and external organisations.

Some environmental factors facilitated the work of the post holder, notably the support from

senior managers and external organisations and the buy-in from health professionals to the

training and professional development opportunities develop by the post holder. Barriers

included the initial lack of strategic and operational vision (including concerns expressed by

colleagues) during the initial introductory phase of the post and the apparent confused lines of

communication and management. The post also appeared to lack administrative support.

4.1 Framing the results

Nurse Consultant posts traditionally have four key areas of activity; Clinical, Education,

Leadership and Research. To date the greatest proportion of activity has been focussed on

providing clinical leadership to 3 Advanced Nurse Practitioners (ANPs) in the health board

area. There is a degree of crossover therefore between leadership, clinical and education

activities.

4.1.1 Professional impact

The creation of a senior clinical nursing role provides a career pathway for community

nurses.

It is clear that the post holder has been the driving force in the creation and development of

the three Advanced Nurse Practitioner posts. In terms of professional impact, the work of the

post holder, in collaboration with Higher Education Institutions, to design and implement the

competency framework for the ANPs has been the major contribution to professional

advancement. This output is now being used as a blueprint for the benefit of wider

community nursing staff, in terms of the adaptation of the competency framework for Band

5/6 nurses.

It could be argued that there was a need and a role for strong clinical leadership during the

recent re-structuring of district nursing services. There was no evidence to suggest that this

wider workforce has yet benefitted from this post.

22 Ibid




4.1.2 Clinical impact

It has been established that the post has, until recently, had no direct clinical contact with

patients. The potential clinical impact has therefore been as a result of the post holder’s

contributory or leadership role in bringing a number of initiatives to fruition. It is clear that

the development of the Community Wards, the work on Living and Dying Well in the

community and Anticipatory Care Pathways would not have progressed to the same extent in

the absence of this post.

4.2 Barriers

The post of Community Nurse Consultant was introduced opportunistically rather than part of

a strategic plan for community nursing within the health board area. As such it lacked a clear

remit or direction at the outset.

Within the organisation there was a lack of clarity or understanding about where this post sat

within the managerial/clinical tree and its lines of responsibility and accountability.

The decision to host this post within the PC&MH Services directorate was taken in order that

the AND could provide support and direction to the post. While there is evidence that this

relationship has worked well, it also created a distance between the post and those working in

the district nursing service that were positioned within a parallel management structure.

The lack of administrative support has resulted in an uneconomic use of the Nurse

Consultant’s time which is not commensurate with the function or level of seniority of the

role.

4.3 Future direction

The piloting of a Community Nurse Consultant post has allowed the QNIS and the health

board to evaluate the initial introductory phase of the role. Going forward, there are a number

of issues highlighted through this evaluation which, if addressed, could enhance and support

similar posts.

a) The introduction of a Community Nurse Consultant post should be informed by a strategic

planning process which clearly identifies the need for such a role, in terms of vision and how

the work will contribute to the development of the four key aspects of a Nurse Consultant’s

post namely Clinical, Education, Leadership and Research.

b) The CNC should be housed within the same clinical directorate, or similar structure, as the

branch of nursing to which they are aligned. In this case that means that the Nurse Consultant

should be a visible and accessible resource to all nurses working within district nursing

services.




c) Given the initial reactions by other health professions it would be worth consulting with

key stakeholders prior to the introduction of such a post to assess the level buy-in and work

towards a critical level of acceptance.

d) The sustainability of the post requires some thought including structural support and the

possibility of full-time hours.

Unlike many other Nurse Consultant posts which are ‘disease-specific’ the CNC has a more

reactive role across community care. While this could be regarded as a challenge, it can also

be seen as a flexible resource which can adapt to changing needs and healthcare priorities

within the community.

At this time many of the developmental projects undertaken by the post holder haves reached

a level where they can now be managed by operational managers and practitioners.

e) The evidence suggests that the focus should now be on identifying the support needs of the

district nursing services, particularly in the development of new skills and roles previously

carried out by hospital-based staff. The Nurse Consultant has a key leadership role to play in

the development or adaptation of competency frameworks and training for Band 5/6 nurses.

f) In order to provide ongoing clinical leadership, priority should be given to defining and

establishing a substantive clinical consultancy function for the post.

Documents

An evaluation of the Community Nurse Consultant Pilot Project in an NHS Health Board in Scotland