PROFESSIONAL
The fundamental managerial challenges in the role of a contemporary district nurse: A discussion Florence McComiskey RGN Community staff nurse, South Eastern Trust, Northern Ireland
S
© 2017 MA Healthcare Ltd
ome of the fundamental challenges facing the managerial role of the district nurse in contemporary practice will be examined, as this is a time of organisational restructuring and financial constraints (Imison et al, 2016). An increasing ageing population, often with multiple complex health needs, and a focus for more patient-centred care in the patient’s home, mean that the need for the specialist expertise of the district nurse’s managerial role has never been more central to the provision of care (Saunders, 2016). District nursing services are now required to respond to the changing population and political needs (Ryder and Bain, 2013), while also maintaining 24-hour responsibility for larger and more diverse caseloads. Increasing acuity, frailty and demand for meaningful person-centred outcomes for patients and carers—which evolve around ethnic diversity, disease risk and comorbidities—are now integral to care provision (Department of Health (DH), 2016). The focus is directed towards enabling people to make more positive, healthier choices, and to self-manage and maintain control on quality of life (DH, 2015). This already complex and unpredictable dimension of the service is challenged further by lack of planning for transitions of care from hospital to home (Queen’s Nursing Institute (QNI), 2014). Patients are increasingly being discharged home when more acutely unwell. Indeed, hospital admission is often avoided and complexity is increased by treating patients at home who previously would have been hospitalised. As the need for this service rises, it faces a serious shortfall in capacity and financial investment (QNI, 2016; Robertson et al, 2017).
Personal requirements and team working Within the manager role, the district nurse is the link between middle management and front-line personal care delivery. To ensure the provision of a quality service that is underpinned at all levels by a compassionate ethos,
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engagement and commitment to staff are essential (Oldham, 2014). Without team cooperation, delivering meaningful care is impossible. It is the district nurse’s role to ensure staff are working well together as they are the main resource of the service (Bliss, 2013). In the community, this is more pertinent and challenging than in other settings, due to increased isolation in lone working and increased autonomous practice.This necessitates the need for more emotional and psychological support within district nursing teams. It is essential that the manager has high emotional intelligence, communication and organisational skills, and applies the ethos of person-centred care; not only to patients and
ABSTRACT
This article examines some of the fundamental challenges facing the district nurse in delivery of the managerial aspects of her role in contemporary practice. It discusses the personal attributes that are essential for this role to ensure safe, effective and compassionate leadership and management. The communication skills and ethos underpinning collaborative multidiscilplinary team work and person-centred care are discussed. Issues that compromise positive and productive team working are identified, and strategies dealing with conflict and also change management are debated. These factors are interrelated with the everyday demands of caseload management, the development of educational needs to meet the demands of increased complexity in care needs, and the place of technology in modern health care. It is evidenced that sustained organisational support for this role is more important than ever, due to increasing demand and decreasing capacity. Potential solutions to these challenges are offered to assist the contemporary district nurse.
KEY WORDS
w emotional intelligence w collaborative team working w change and conflict management skills w political awareness w organisational support
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culture of learning and continuous improvement. With this approach, the management of conflict should not be regarded as adverse (Almost et al, 2016). It is everyone’s responsibility to work cooperatively (NMC, 2015), but the district nurse should be more sensitive to factors that may contribute to destabilising, obstructive conflict.This requires being intuitive in their thinking and attempting to detect and deal with predisposing issues early on to avoid unnecessary escalation. It is essential to promote team working and ensure conflict is managed so that it does not increase work stress and prevent the effective working of the team. Active listening and the use of communication skills, which reinforce a genuine concern to effectively manage the situation, should be used. Conflict resolution strategies include ThomasKilmann’s five styles, centred around competition, accommodation, avoiding, compromise or collaboration (Kilmann and Thomas, 1977). Lower levels of conflict have been reported in people with high levels of emotional intelligence, who were more likely to use collaborative or compromising styles of conflict resolution. This was also reported by those who developed knowledge about the situation and were mentally prepared and confidently assertive in their ability to move forward (Ellis and Abbot, 2013).The manager must select the most appropriate strategy at an early stage and not be afraid to address difficult issues and fulfil their duty to always act in the best interest of the patient and the team (NMC, 2015).
Facilitating change Interrelated with conflict management is the integration of change management into team working, as change without some opposition is not seen as change at all (Norman, 2012). Change is inevitable due to the influences of new political policies and new needs in demographics (Dickson et al, 2011). As debated by Norman (2012), there is a duty to ensure an optimum level of service improvement and so this requires small changes to be implemented. Indeed, the Department of Health (2016) clarified the need for the workforce to be empowered and engaged in originating new ways of working. Fundamental to such change is achieving commitment and involvement from those attached to the team, and using advanced interpersonal skills as discussed. The district nurse must explain why change is necessary and demonstrate how it can be achieved. Change is a challenge and can increase stress and isolation. Pervasive factors that can impede the process, such as lack of time or training needs, must be anticipated and managed appropriately. Harris et al (2014) advised sharing and agreeing goals, ensuring feedback and offering encouragement. Norman (2012) promoted openly discussing resistance factors, using one-to-one or group discussions and persuading those who have a positive view to help integrate it. Lewin’s force model is often used and contributes to identifying barriers (Sutherland, 2013). Underpinning all of these strategies is the need to recognise that team cooperation is crucial to this process, and that learning from mistakes is enhancing. Moreover, time and trust are always essential to allow relationships and processes to progress.
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families, but also to all their staff.This requires that they must be honest and self-aware of their own needs and limitations, and be proactive and positive in their self-management of difficult environments. They must be able to recognise signs of stress in their staff by ensuring they know and value them well, and are mindful of predisposing barriers. Listening meaningfully to staff, being available and providing positive and relevant support that is individualised to each staff member’s needs are essential to improve staff morale and motivation. Staff strengths and weaknesses should be identified by the district nurse and managed so that they are improved on and benefit patients and the team as a whole. By paying attention to detail regarding not only the needs of patients but also the needs and skills of team members, the district nurse can build a happier and more productive team. As highlighted by Nyantanga (2014), commitment and collaboration with other colleagues can result in unique and dignified caring. A caring approach should be as important in its application to staff as it is to patients. Staff should be thanked daily for their efforts. A growing culture of collaboration and openness is required (Francis, 2013), with an increased need for interfacing with other community nursing teams and general practice alignment (QNI, 2017). For a manager, this signifies increased focus on supporting good interdisciplinary and multidisciplinary relationships. If meaningful integrated care is to be provided, a culture of approachability and support must be in place among health professionals. The district nurse must lead by example and promote working practices that build on multidisciplinary networking, nurturing of staff confidence, and ensuring staff feel listened to, respected and empowered (Marquis and Huston, 2015). This can be achieved by ensuring staff are clear on their duties and roles and actively encouraging and making time for open discussions. Regular team meetings can enhance continuity of care and reassure staff by the sharing of information. It is important to ensure all staff feel equally and fairly treated and provide the same standards of professionalism to each staff member consistently. It is fundamental to ensure staff know the standards and behaviour that are expected of them by ensuring they are familiar with their organisation’s policies and adherence to the Nursing and Midwifery Council (NMC) code of conduct (NMC, 2015). Developing a culture of collective responsibility and goal-sharing will improve morale and patient safety (Storey and Holti, 2013). This can motivate staff to enhance their performance and to be helpful to each other (West et al, 2014). However, this type of compassionate leadership can be compromised by growing administrative duties, which can lead to reduced time and energy for staff support. Despite collaborative working principles, conflict is inevitable due to factors such as stress caused by increased workloads, poor communication, personality traits and resistance to change. If managed appropriately, it can result in better outcomes (Badder et al, 2016) and can improve staff development, team relationships, and enable progressive change through the exchange of creative ideas. This requires clinical leadership that is assertive and inspirational, promoting a
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Inevitably, facilitating change in practice is also dependent on educational development. The courage to challenge and question practice, and indeed the culture of care organisation, is integral to enabling change and progress, and is synonymous with lifelong learning and service improvement. Nursing staff have an individual duty to ensure their knowledge and practice is safe and effective, and they are accountable for their own practice (NMC, 2015). Lifelong learning is associated with augmented capacity to deliver high quality care (Pesut et al, 2015). Increasingly, this is required to address complex care needs and develop expanding roles and innovative clinical experience to improve services. This stance is endorsed by the Public Health Agency (2016) and by the NMC (2015) and therefore it is not an option from an organisational and professional standpoint.
Professional development The district nurse is partly responsible for nurturing a critically questioning environment and creating new ways of working together and implementing improved care. They have the difficult responsibility of ensuring that quality of care is being maintained in a remote setting, thus necessitating a continuous development of effectiveness in person-centred care. Possessing the necessary current knowledge and clinical skills to be a role model are fundamental. Voluntary standards to enhance nurse education and practice for district nurses were implemented by the QNI in 2015, and highlighted that revised standards needed to reflect the expanding complexity of the expert specialism of this role. As a manager, the district nurse has the challenge of facilitating staff to meet mandatory and additional training needs to develop their skills and contribute to new sustainable care models, while also deploying them so that they can still have adequate time to care for patients. Due to increasing inflexibility arising from the growing gap between rising service demand and reduced capacity, it may become more difficult for the district nurse to enable this. Ironically, as complexity in care escalates, the need for training and staff supervision is even greater.There is an undeniable need for commissioners to increase engagement with front-line staff in order for professional development needs to be effectively met through improved workforce planning. The district nurse needs to be proactive and lobby for increased protected time for training. This would avoid relying on staff goodwill to meet simultaneous training and care needs by staff potentially working over their time.
Caseload management Paramount among all of the challenges discussed above, is managing a caseload.The district nurse must manage a caseload, which involves balancing capacity and capability with the needs of patients, families and carers in a designated geographical and/or practice population. The district nurse contributes to, and shares responsibility with GPs, managers and commissioners for ensuring quality, effectiveness and efficiency for this population, while also ensuring equity and cost-effectiveness. Achieving a safe caseload in which staff do not feel overworked and undervalued, and a good patient
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experience is delivered, demands prioritising and delegating calls to the right nurse who has the right skills and who is there at the right time (Department of Health, Social Services and Public Safety Northern Ireland, 2012). Increasing complex demands on the service, and serious shortfalls in recruitment and retention of staff (Jackson et al, 2016), result in the district nurse needing higher levels of clinical judgement, communication, risk assessment and organisational skills (Bain and Baguley, 2012). Caseload management skills are integral with the personal requirements of a district nurse, because without a deep sense of commitment, compassion, organisation and communication ability, this would be a vital aspect of the role that may not be effectively delivered. Caseload management necessitates a need for flexibility to meet unplanned patient needs and new referrals.Advanced professional judgement is essential so that delays to care, unmet needs and stress on carers and staff do not rise. Maintaining efficiency and safety by evaluating delegation of calls against staff numbers, skill mix and working hours available for each staff member will help maintain safe equitable workloads. Organisational factors, such as unsafe staffing levels, could contribute to more task-focused care, and missed opportunities for preventative health care.This could lead to an endangerment of safeguarding needs, and an increase in more complex and costly care in the future. To help address this, the role of the district nurse is surely to become more vocal, and indeed politically active and stipulate when further referrals can no longer be accepted safely and effectively without increased staffing availability. This requires a national unified stance and is comparable to being between a rock and a hard place: nurses want to give patients the care they need even though their time capacity to do this has been totally utilised. To assist with workload management and workforce planning, there are tools available to commissioners such as DominiC in England (Bowers and Durrant, 2014), and the Scottish Nursing Workforce tool (Grafen and Mackenzie, 2015). In Northern Ireland, the electronic caseload analysis tool (eCAT) is used. This helps to evidence the context of population need, nursing activity, dependency, staff resources and service design (Kane, 2014). The data collected can be used to inform and improve performance management and service modernisation. However, there is a need for more refined data collection to demonstrate to service planners the full intensity of care given in each team (Jackson et al, 2016). Presently, these systems are reliant on the quality of the data submitted, give only a snapshot overview and are subjective. They do not reflect the complexity and unpredictability of the service, the emotional demands, or the health promotion and prevention work undertaken. A triangulation approach, comprising numerical data, clinical judgement and a top-down and bottom-up analysis, has been argued as more accurate (Jackson et al, 2015). Although there is a need for more clarity on safe staffing and alignment and standardisation of service models, there is complexity in achieving a benchmark of what are acceptable staffing levels, as service needs across the four countries of the United Kingdom will not be identical.
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PROFESSIONAL
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Embracing technological innovation As highlighted by Bowers and Pellett (2013), district nursing can be supported by technology to adapt to and meet the changing needs of local populations and maximise patient independence. Developments such as telehealth and telecare have contributed to a new sense of control and user involvement for patients, while also reducing hospital admissions (DH, 2015). From a staff perspective, information technology has facilitated quick information sharing between community, hospital and social care systems, and has enhanced joined-up care. This is particularly pertinent in a community setting where better communication is important due to frequent multidisciplinary working in more remote areas.Technology aims to improve communication in continuity of care and reduce duplication. It has facilitated readier accessing of many sources of clinical data, thus accelerating attainment of diagnosis and treatment. Patient experience and empowerment, and safety and quality of care can be improved as services are brought closer to home, improving outcomes. Nevertheless, there are ongoing difficulties in technology implementation. Staff time and skills are not always available in this area, thus stifling innovative progress. Frequently it is not possible to get individualised training due to lack of specialised trainers and availability of travelling time, as well as actual training time. These issues compound the mistrust and fear some staff may have of technology. Experienced staff can feel threatened by the expectation of being skilled in this domain. Conversely, they feel it may reduce the quality of therapeutic relationships as it enables streamlining of visits and information gathering without direct patient contact. It is the duty not only of the manager, but also the organisation, to support staff, build their confidence and to embrace technology as a vital component of modern health care. Solutions to this may involve the democratic appointment of team technology link nurses who can support staff in adopting this change, and who can share this role to meet the needs of individuals at an acceptable pace for those needing support. It should also be factored into the computed workload records of staff to strengthen the need for more resources. Technology has a key role in future health care and professional bodies such as the QNI (2015) have clarified that not ensuring this competency could present a concern in fitness to practice. Advanced communication, and change and conflict management skills are clearly essential.
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Conclusions This discussion has offered potential solutions to the demands of delivering the fundamental managerial aspects of the district nursing role. It has demonstrated the need for a resilient and determined practitioner who has consistent high levels of emotional intelligence, communication skills, commitment and honesty. Inseparable from this is the district nurse’s own need for increased senior organisational support, and the impact of workforce and educational planning, and regional consistency on equipping the district nursing
KEY POINTS
ww Emotional intelligence, commitment, communication, and honesty to ensure effective leadership and management. ww Collaborative team working to deliver safe and effective care. ww Change and conflict management skills to facilitate progress. ww Commitment to educational development and technology to meet complex care needs. ww Increased political awareness and organisational support to sustain the district nurse in this role when facing increasing demand with fewer resources.
manager to facilitate sustainment of effective services. Commissioners must involve front-line staff more in service change and planning and equally front-line staff must utilise opportunities to influence systems. Emphasis has been placed on the importance of inspiring team collaboration and shared decision-making. These elements are fundamental to empowering and encouraging staff to embrace change and improvement for the greater benefit of the whole team and ultimately for patients and carers. Increasing demand and complexity necessitate that this relational dimension of management is consolidated with robust clinical leadership and advanced assessment skills.The manager must lead by example, prioritising compassion in care and quality improvement. It is a dynamic environment requiring sustained flexibility, and adaptability from an enthusiastic and professional manager who is willing to challenge the status quo and who is supported by an effective infrastructure. BJCN Accepted for publication: September 2017 Declaration of interest: None Almost J, Wolff A, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an integrated review. J Adv Nurs. 2016;72(7):1490–1505 Badder F, Salem A, Hazel N. Conflict resolution strategies of nurses in a selected tertiary hospital in the kingdom of Saudi Arabia. J Nurs Education Practice. 2016;6(5):91 Bain H, Baguley F. The management of caseloads in district nursing services. Primary Health Care. 2012;22(4):31–7 Bliss J. Effective team management by district nurses. Br J Community Nurs. 2013;9(12):524–6 Bowers B, Durrant K. Measuring safe staff levels in the community: the DominiC workforce management tool. Br J Community Nurs. 2014;19(2):58–64 Bowers B, Pellett C. Measuring the clinical effectiveness of district nurses. Br J Community Nurs. 2013;18(7):332–7 Department of Health. Compassion in practice: nursing, midwifery and care staff. Our vision and strategy. 2012. https://www.england.nhs.uk/wp-content/ uploads/2012/12/compassion-in-practice.pdf (accessed 13 September 2017) Department of Health. 2010 to 2015 government policy: long term conditions. 2015. https://www.gov.uk/government/publications/2010-to-2015-government-policy-long-term-health-conditions/2010-to-2015-government-policy-long-term-health-conditions (accessed 13 September 2017) Department of Health. Systems not structures: changing health and social care. 2016. https://www.health-ni.gov.uk/sites/default/files/publications/health/ expert-panel-full-report.pdf (accessed 13 September 2017) Department of Health, Social Services and Public Safety Northern Ireland. Quality 2020 – A 10-year strategy for health and social care in Northern Ireland. 2012. https://www.health-ni.gov.uk/sites/default/files/publications/ dhssps/q2020-strategy.pdf (accessed 13 September 2017) Dickson C, Gough H, Bain H. Meeting the policy agenda, part 1: the role of the modern district nurse. Br J Community Nurs. 2011;16(10):495–500
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CPD REFLECTIVE QUESTIONS ww As a district nurse, how do you manage change? ww How can district nurses influence service planning to facilitate more effective caseload management? ww How can the personal and professional qualities needed to be a district nurse be enhanced? ww What strategies can a district nurse use to productively manage conflict? ww How can the district nurse improve team working and multidisciplinary networking?
Ellis P, Abbot J. Leadership and management skills in healthcare. Nurse Prescribing. 2013;11(5):251-254. Francis R. Report of the Mid-Staffordshire National Health Service foundation trust public inquiry. 2013. https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/279124/0947.pdf (accessed 13 September 2017) Grafen M, Mackenzie F. Development and early application of the Scottish community nursing workload measurement tool. Br J Community Nurs. 2015;20(2):89–92 Harris R, Bennett J, Ross F. Leadership and innovation in nursing seen through a holistic lens. J Adv Nurs. 2014;70(7):1629–38 Imison C, Castle-Clarke S, Watson R. Reshaping the workforce to deliver the care patients need. Research project. 2016. https://www.nuffieldtrust.org.uk/ files/2017-01/reshaping-the-workforce-web-final.pdf (accessed 13 September 2017) Jackson C, Leadbetter T, Manley K, Martin A. Making the complexity of community nursing visible: the Cassandra project. Br J Community Nurs. 2015;20(3):127–32 Jackson C, Wright T, Martin A. Safe improvements for adult community nursing services- an updated review of the evidence. 2016. https://improvement. nhs.uk/uploads/documents/Final_Version_Managing_Safe_Caseloads.pdf (accessed 13 September 2017) Kane K. Capturing district nursing through a knowledge based electronic analysis tool (eCAT). Br J Community Nurs. 2014;19(3):116–24 Kilmann RH, Thomas KW. Developing a forced choice measure of conflict handling behaviour: The Mode instrument. Educat Psychologic Measure. 1977;37(2):309–25 Marquis BL, Huston CJ. Leadership roles and management functions in nursing.
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In: Theory and application. 8th ed. London: Wolters Kluwer; 2015 Maybin J, Charles A, Honeyman M. Understanding quality in district nursing services. Learning from patients, staff and carers. 2016. http://bit.ly/2y6vUkI (accessed 13 September 2017) Norman K. Leading service improvement in changing times. Br J Community Nurs. 2012;17(4):162–7 Nursing and Midwifery Council. The code – standards of conduct, performance and ethics for nurses and midwives. 2015. https://www.nmc.org.uk/globalassets/ sitedocuments/nmc-publications/nmc-code.pdf (accessed 13 September 2017) Nyantanga B. Relationships between community nurses and other health care professionals. Br J Community Nurs. 2014;19(2):100 Oldham C. The district nursing service: a national treasure. Br J Community Nurs. 2014;19(8):394–5 Pesut B, McLean T, Reimer-Kirkham S, et al. Educating registered nursing and healthcare assistant students in community- based supportive care of older adults: a mixed methods study. Nurse Education Today. 2015;35(9):e90-e96 Public Health Agency. What matters? A vision for nursing in older people’s services. 2016. http://bit.ly/2vUFfKK (accessed 13 September 2017) Queen’s Nursing Institute. Discharge planning: best practice in transitions of care. 2014. https://www.qni.org.uk/wp-content/uploads/2016/09/discharge_ planning_report_2015.pdf (accessed 13 September 2017) Queen’s Nursing Institute. District Nursing in the digital age. 2015. https://www. jcn.co.uk/news/district-nursing-in-the-digital-age-transforming-district-andcommunity-nursing- (accessed 15 September 2017) Queen’s Nursing Institute. Understanding safe caseloads in the district nursing service. 2016. https://www.qni.org.uk/wp-content/uploads/2017/02/ Understanding_Safe_Caseloads_in_District_Nursing_Service_V1.0.pdf (accessed 13 September 2017) Queen’s Nursing Institute. Transition to district nursing service. 2017. https:// www.qni.org.uk/wp-content/uploads/2017/01/Transition-to-DistrictNursing.pdf (accessed 13 September 2017) Robertson R, Wenzel L, Thompson J, Charles A. Understanding NHS financial pressures. How are they affecting patient care. 2017. http://bit.ly/2h3MbTs (accessed 13 September 2017) Royal College of Nursing.The Buurtzorg Nederland (home care provider) model. 2015. http://bit.ly/2h3GhOj (accessed 13 September 2017) Ryder E, Bain H. Revitalising district nursing. Br J Community Nurs. 2013;18(7):317 Saunders, M. Developing voluntary standards for district nurse education and practice. Br J Community Nurs. 2016;21(5):240–5 Storey J, Holti R. Towards a new model of leadership for the NHS. 2013. https:// www.leadershipacademy.nhs.uk/wp-content/uploads/dlm_uploads/2014/10/ Towards-a-New-Model-of-Leadership-2013.pdf (accessed 13 September 2017) Sutherland K. Applying Lewin’s change management theory to the implementation of bar coded medication administration. Canadian J Nurs Informatics. 2013;8(1-2) West M, Eckert R, Steward K, Pasmore B. Developing collective leadership for healthcare. 2014. https://www.kingsfund.org.uk/.../developing-collectiveleadership-kingsfund-may14.pdf (accessed 13 September 2017)
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The fundamental managerial challenges in the role of a contemporary district nurse: A discussion Florence McComiskey RGN Community staff nurse, South Eastern Trust, Northern Ireland
S
© 2017 MA Healthcare Ltd
ome of the fundamental challenges facing the managerial role of the district nurse in contemporary practice will be examined, as this is a time of organisational restructuring and financial constraints (Imison et al, 2016). An increasing ageing population, often with multiple complex health needs, and a focus for more patient-centred care in the patient’s home, mean that the need for the specialist expertise of the district nurse’s managerial role has never been more central to the provision of care (Saunders, 2016). District nursing services are now required to respond to the changing population and political needs (Ryder and Bain, 2013), while also maintaining 24-hour responsibility for larger and more diverse caseloads. Increasing acuity, frailty and demand for meaningful person-centred outcomes for patients and carers—which evolve around ethnic diversity, disease risk and comorbidities—are now integral to care provision (Department of Health (DH), 2016). The focus is directed towards enabling people to make more positive, healthier choices, and to self-manage and maintain control on quality of life (DH, 2015). This already complex and unpredictable dimension of the service is challenged further by lack of planning for transitions of care from hospital to home (Queen’s Nursing Institute (QNI), 2014). Patients are increasingly being discharged home when more acutely unwell. Indeed, hospital admission is often avoided and complexity is increased by treating patients at home who previously would have been hospitalised. As the need for this service rises, it faces a serious shortfall in capacity and financial investment (QNI, 2016; Robertson et al, 2017).
Personal requirements and team working Within the manager role, the district nurse is the link between middle management and front-line personal care delivery. To ensure the provision of a quality service that is underpinned at all levels by a compassionate ethos,
[email protected]
engagement and commitment to staff are essential (Oldham, 2014). Without team cooperation, delivering meaningful care is impossible. It is the district nurse’s role to ensure staff are working well together as they are the main resource of the service (Bliss, 2013). In the community, this is more pertinent and challenging than in other settings, due to increased isolation in lone working and increased autonomous practice.This necessitates the need for more emotional and psychological support within district nursing teams. It is essential that the manager has high emotional intelligence, communication and organisational skills, and applies the ethos of person-centred care; not only to patients and
ABSTRACT
This article examines some of the fundamental challenges facing the district nurse in delivery of the managerial aspects of her role in contemporary practice. It discusses the personal attributes that are essential for this role to ensure safe, effective and compassionate leadership and management. The communication skills and ethos underpinning collaborative multidiscilplinary team work and person-centred care are discussed. Issues that compromise positive and productive team working are identified, and strategies dealing with conflict and also change management are debated. These factors are interrelated with the everyday demands of caseload management, the development of educational needs to meet the demands of increased complexity in care needs, and the place of technology in modern health care. It is evidenced that sustained organisational support for this role is more important than ever, due to increasing demand and decreasing capacity. Potential solutions to these challenges are offered to assist the contemporary district nurse.
KEY WORDS
w emotional intelligence w collaborative team working w change and conflict management skills w political awareness w organisational support
British Journal of Community Nursing October 2017 Vol 22, No 10
489
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 203.002.032.208 on October 18, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
PROFESSIONAL
490
culture of learning and continuous improvement. With this approach, the management of conflict should not be regarded as adverse (Almost et al, 2016). It is everyone’s responsibility to work cooperatively (NMC, 2015), but the district nurse should be more sensitive to factors that may contribute to destabilising, obstructive conflict.This requires being intuitive in their thinking and attempting to detect and deal with predisposing issues early on to avoid unnecessary escalation. It is essential to promote team working and ensure conflict is managed so that it does not increase work stress and prevent the effective working of the team. Active listening and the use of communication skills, which reinforce a genuine concern to effectively manage the situation, should be used. Conflict resolution strategies include ThomasKilmann’s five styles, centred around competition, accommodation, avoiding, compromise or collaboration (Kilmann and Thomas, 1977). Lower levels of conflict have been reported in people with high levels of emotional intelligence, who were more likely to use collaborative or compromising styles of conflict resolution. This was also reported by those who developed knowledge about the situation and were mentally prepared and confidently assertive in their ability to move forward (Ellis and Abbot, 2013).The manager must select the most appropriate strategy at an early stage and not be afraid to address difficult issues and fulfil their duty to always act in the best interest of the patient and the team (NMC, 2015).
Facilitating change Interrelated with conflict management is the integration of change management into team working, as change without some opposition is not seen as change at all (Norman, 2012). Change is inevitable due to the influences of new political policies and new needs in demographics (Dickson et al, 2011). As debated by Norman (2012), there is a duty to ensure an optimum level of service improvement and so this requires small changes to be implemented. Indeed, the Department of Health (2016) clarified the need for the workforce to be empowered and engaged in originating new ways of working. Fundamental to such change is achieving commitment and involvement from those attached to the team, and using advanced interpersonal skills as discussed. The district nurse must explain why change is necessary and demonstrate how it can be achieved. Change is a challenge and can increase stress and isolation. Pervasive factors that can impede the process, such as lack of time or training needs, must be anticipated and managed appropriately. Harris et al (2014) advised sharing and agreeing goals, ensuring feedback and offering encouragement. Norman (2012) promoted openly discussing resistance factors, using one-to-one or group discussions and persuading those who have a positive view to help integrate it. Lewin’s force model is often used and contributes to identifying barriers (Sutherland, 2013). Underpinning all of these strategies is the need to recognise that team cooperation is crucial to this process, and that learning from mistakes is enhancing. Moreover, time and trust are always essential to allow relationships and processes to progress.
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families, but also to all their staff.This requires that they must be honest and self-aware of their own needs and limitations, and be proactive and positive in their self-management of difficult environments. They must be able to recognise signs of stress in their staff by ensuring they know and value them well, and are mindful of predisposing barriers. Listening meaningfully to staff, being available and providing positive and relevant support that is individualised to each staff member’s needs are essential to improve staff morale and motivation. Staff strengths and weaknesses should be identified by the district nurse and managed so that they are improved on and benefit patients and the team as a whole. By paying attention to detail regarding not only the needs of patients but also the needs and skills of team members, the district nurse can build a happier and more productive team. As highlighted by Nyantanga (2014), commitment and collaboration with other colleagues can result in unique and dignified caring. A caring approach should be as important in its application to staff as it is to patients. Staff should be thanked daily for their efforts. A growing culture of collaboration and openness is required (Francis, 2013), with an increased need for interfacing with other community nursing teams and general practice alignment (QNI, 2017). For a manager, this signifies increased focus on supporting good interdisciplinary and multidisciplinary relationships. If meaningful integrated care is to be provided, a culture of approachability and support must be in place among health professionals. The district nurse must lead by example and promote working practices that build on multidisciplinary networking, nurturing of staff confidence, and ensuring staff feel listened to, respected and empowered (Marquis and Huston, 2015). This can be achieved by ensuring staff are clear on their duties and roles and actively encouraging and making time for open discussions. Regular team meetings can enhance continuity of care and reassure staff by the sharing of information. It is important to ensure all staff feel equally and fairly treated and provide the same standards of professionalism to each staff member consistently. It is fundamental to ensure staff know the standards and behaviour that are expected of them by ensuring they are familiar with their organisation’s policies and adherence to the Nursing and Midwifery Council (NMC) code of conduct (NMC, 2015). Developing a culture of collective responsibility and goal-sharing will improve morale and patient safety (Storey and Holti, 2013). This can motivate staff to enhance their performance and to be helpful to each other (West et al, 2014). However, this type of compassionate leadership can be compromised by growing administrative duties, which can lead to reduced time and energy for staff support. Despite collaborative working principles, conflict is inevitable due to factors such as stress caused by increased workloads, poor communication, personality traits and resistance to change. If managed appropriately, it can result in better outcomes (Badder et al, 2016) and can improve staff development, team relationships, and enable progressive change through the exchange of creative ideas. This requires clinical leadership that is assertive and inspirational, promoting a
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Inevitably, facilitating change in practice is also dependent on educational development. The courage to challenge and question practice, and indeed the culture of care organisation, is integral to enabling change and progress, and is synonymous with lifelong learning and service improvement. Nursing staff have an individual duty to ensure their knowledge and practice is safe and effective, and they are accountable for their own practice (NMC, 2015). Lifelong learning is associated with augmented capacity to deliver high quality care (Pesut et al, 2015). Increasingly, this is required to address complex care needs and develop expanding roles and innovative clinical experience to improve services. This stance is endorsed by the Public Health Agency (2016) and by the NMC (2015) and therefore it is not an option from an organisational and professional standpoint.
Professional development The district nurse is partly responsible for nurturing a critically questioning environment and creating new ways of working together and implementing improved care. They have the difficult responsibility of ensuring that quality of care is being maintained in a remote setting, thus necessitating a continuous development of effectiveness in person-centred care. Possessing the necessary current knowledge and clinical skills to be a role model are fundamental. Voluntary standards to enhance nurse education and practice for district nurses were implemented by the QNI in 2015, and highlighted that revised standards needed to reflect the expanding complexity of the expert specialism of this role. As a manager, the district nurse has the challenge of facilitating staff to meet mandatory and additional training needs to develop their skills and contribute to new sustainable care models, while also deploying them so that they can still have adequate time to care for patients. Due to increasing inflexibility arising from the growing gap between rising service demand and reduced capacity, it may become more difficult for the district nurse to enable this. Ironically, as complexity in care escalates, the need for training and staff supervision is even greater.There is an undeniable need for commissioners to increase engagement with front-line staff in order for professional development needs to be effectively met through improved workforce planning. The district nurse needs to be proactive and lobby for increased protected time for training. This would avoid relying on staff goodwill to meet simultaneous training and care needs by staff potentially working over their time.
Caseload management Paramount among all of the challenges discussed above, is managing a caseload.The district nurse must manage a caseload, which involves balancing capacity and capability with the needs of patients, families and carers in a designated geographical and/or practice population. The district nurse contributes to, and shares responsibility with GPs, managers and commissioners for ensuring quality, effectiveness and efficiency for this population, while also ensuring equity and cost-effectiveness. Achieving a safe caseload in which staff do not feel overworked and undervalued, and a good patient
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experience is delivered, demands prioritising and delegating calls to the right nurse who has the right skills and who is there at the right time (Department of Health, Social Services and Public Safety Northern Ireland, 2012). Increasing complex demands on the service, and serious shortfalls in recruitment and retention of staff (Jackson et al, 2016), result in the district nurse needing higher levels of clinical judgement, communication, risk assessment and organisational skills (Bain and Baguley, 2012). Caseload management skills are integral with the personal requirements of a district nurse, because without a deep sense of commitment, compassion, organisation and communication ability, this would be a vital aspect of the role that may not be effectively delivered. Caseload management necessitates a need for flexibility to meet unplanned patient needs and new referrals.Advanced professional judgement is essential so that delays to care, unmet needs and stress on carers and staff do not rise. Maintaining efficiency and safety by evaluating delegation of calls against staff numbers, skill mix and working hours available for each staff member will help maintain safe equitable workloads. Organisational factors, such as unsafe staffing levels, could contribute to more task-focused care, and missed opportunities for preventative health care.This could lead to an endangerment of safeguarding needs, and an increase in more complex and costly care in the future. To help address this, the role of the district nurse is surely to become more vocal, and indeed politically active and stipulate when further referrals can no longer be accepted safely and effectively without increased staffing availability. This requires a national unified stance and is comparable to being between a rock and a hard place: nurses want to give patients the care they need even though their time capacity to do this has been totally utilised. To assist with workload management and workforce planning, there are tools available to commissioners such as DominiC in England (Bowers and Durrant, 2014), and the Scottish Nursing Workforce tool (Grafen and Mackenzie, 2015). In Northern Ireland, the electronic caseload analysis tool (eCAT) is used. This helps to evidence the context of population need, nursing activity, dependency, staff resources and service design (Kane, 2014). The data collected can be used to inform and improve performance management and service modernisation. However, there is a need for more refined data collection to demonstrate to service planners the full intensity of care given in each team (Jackson et al, 2016). Presently, these systems are reliant on the quality of the data submitted, give only a snapshot overview and are subjective. They do not reflect the complexity and unpredictability of the service, the emotional demands, or the health promotion and prevention work undertaken. A triangulation approach, comprising numerical data, clinical judgement and a top-down and bottom-up analysis, has been argued as more accurate (Jackson et al, 2015). Although there is a need for more clarity on safe staffing and alignment and standardisation of service models, there is complexity in achieving a benchmark of what are acceptable staffing levels, as service needs across the four countries of the United Kingdom will not be identical.
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PROFESSIONAL
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Embracing technological innovation As highlighted by Bowers and Pellett (2013), district nursing can be supported by technology to adapt to and meet the changing needs of local populations and maximise patient independence. Developments such as telehealth and telecare have contributed to a new sense of control and user involvement for patients, while also reducing hospital admissions (DH, 2015). From a staff perspective, information technology has facilitated quick information sharing between community, hospital and social care systems, and has enhanced joined-up care. This is particularly pertinent in a community setting where better communication is important due to frequent multidisciplinary working in more remote areas.Technology aims to improve communication in continuity of care and reduce duplication. It has facilitated readier accessing of many sources of clinical data, thus accelerating attainment of diagnosis and treatment. Patient experience and empowerment, and safety and quality of care can be improved as services are brought closer to home, improving outcomes. Nevertheless, there are ongoing difficulties in technology implementation. Staff time and skills are not always available in this area, thus stifling innovative progress. Frequently it is not possible to get individualised training due to lack of specialised trainers and availability of travelling time, as well as actual training time. These issues compound the mistrust and fear some staff may have of technology. Experienced staff can feel threatened by the expectation of being skilled in this domain. Conversely, they feel it may reduce the quality of therapeutic relationships as it enables streamlining of visits and information gathering without direct patient contact. It is the duty not only of the manager, but also the organisation, to support staff, build their confidence and to embrace technology as a vital component of modern health care. Solutions to this may involve the democratic appointment of team technology link nurses who can support staff in adopting this change, and who can share this role to meet the needs of individuals at an acceptable pace for those needing support. It should also be factored into the computed workload records of staff to strengthen the need for more resources. Technology has a key role in future health care and professional bodies such as the QNI (2015) have clarified that not ensuring this competency could present a concern in fitness to practice. Advanced communication, and change and conflict management skills are clearly essential.
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Conclusions This discussion has offered potential solutions to the demands of delivering the fundamental managerial aspects of the district nursing role. It has demonstrated the need for a resilient and determined practitioner who has consistent high levels of emotional intelligence, communication skills, commitment and honesty. Inseparable from this is the district nurse’s own need for increased senior organisational support, and the impact of workforce and educational planning, and regional consistency on equipping the district nursing
KEY POINTS
ww Emotional intelligence, commitment, communication, and honesty to ensure effective leadership and management. ww Collaborative team working to deliver safe and effective care. ww Change and conflict management skills to facilitate progress. ww Commitment to educational development and technology to meet complex care needs. ww Increased political awareness and organisational support to sustain the district nurse in this role when facing increasing demand with fewer resources.
manager to facilitate sustainment of effective services. Commissioners must involve front-line staff more in service change and planning and equally front-line staff must utilise opportunities to influence systems. Emphasis has been placed on the importance of inspiring team collaboration and shared decision-making. These elements are fundamental to empowering and encouraging staff to embrace change and improvement for the greater benefit of the whole team and ultimately for patients and carers. Increasing demand and complexity necessitate that this relational dimension of management is consolidated with robust clinical leadership and advanced assessment skills.The manager must lead by example, prioritising compassion in care and quality improvement. It is a dynamic environment requiring sustained flexibility, and adaptability from an enthusiastic and professional manager who is willing to challenge the status quo and who is supported by an effective infrastructure. BJCN Accepted for publication: September 2017 Declaration of interest: None Almost J, Wolff A, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an integrated review. J Adv Nurs. 2016;72(7):1490–1505 Badder F, Salem A, Hazel N. Conflict resolution strategies of nurses in a selected tertiary hospital in the kingdom of Saudi Arabia. J Nurs Education Practice. 2016;6(5):91 Bain H, Baguley F. The management of caseloads in district nursing services. Primary Health Care. 2012;22(4):31–7 Bliss J. Effective team management by district nurses. Br J Community Nurs. 2013;9(12):524–6 Bowers B, Durrant K. Measuring safe staff levels in the community: the DominiC workforce management tool. Br J Community Nurs. 2014;19(2):58–64 Bowers B, Pellett C. Measuring the clinical effectiveness of district nurses. Br J Community Nurs. 2013;18(7):332–7 Department of Health. Compassion in practice: nursing, midwifery and care staff. Our vision and strategy. 2012. https://www.england.nhs.uk/wp-content/ uploads/2012/12/compassion-in-practice.pdf (accessed 13 September 2017) Department of Health. 2010 to 2015 government policy: long term conditions. 2015. https://www.gov.uk/government/publications/2010-to-2015-government-policy-long-term-health-conditions/2010-to-2015-government-policy-long-term-health-conditions (accessed 13 September 2017) Department of Health. Systems not structures: changing health and social care. 2016. https://www.health-ni.gov.uk/sites/default/files/publications/health/ expert-panel-full-report.pdf (accessed 13 September 2017) Department of Health, Social Services and Public Safety Northern Ireland. Quality 2020 – A 10-year strategy for health and social care in Northern Ireland. 2012. https://www.health-ni.gov.uk/sites/default/files/publications/ dhssps/q2020-strategy.pdf (accessed 13 September 2017) Dickson C, Gough H, Bain H. Meeting the policy agenda, part 1: the role of the modern district nurse. Br J Community Nurs. 2011;16(10):495–500
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CPD REFLECTIVE QUESTIONS ww As a district nurse, how do you manage change? ww How can district nurses influence service planning to facilitate more effective caseload management? ww How can the personal and professional qualities needed to be a district nurse be enhanced? ww What strategies can a district nurse use to productively manage conflict? ww How can the district nurse improve team working and multidisciplinary networking?
Ellis P, Abbot J. Leadership and management skills in healthcare. Nurse Prescribing. 2013;11(5):251-254. Francis R. Report of the Mid-Staffordshire National Health Service foundation trust public inquiry. 2013. https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/279124/0947.pdf (accessed 13 September 2017) Grafen M, Mackenzie F. Development and early application of the Scottish community nursing workload measurement tool. Br J Community Nurs. 2015;20(2):89–92 Harris R, Bennett J, Ross F. Leadership and innovation in nursing seen through a holistic lens. J Adv Nurs. 2014;70(7):1629–38 Imison C, Castle-Clarke S, Watson R. Reshaping the workforce to deliver the care patients need. Research project. 2016. https://www.nuffieldtrust.org.uk/ files/2017-01/reshaping-the-workforce-web-final.pdf (accessed 13 September 2017) Jackson C, Leadbetter T, Manley K, Martin A. Making the complexity of community nursing visible: the Cassandra project. Br J Community Nurs. 2015;20(3):127–32 Jackson C, Wright T, Martin A. Safe improvements for adult community nursing services- an updated review of the evidence. 2016. https://improvement. nhs.uk/uploads/documents/Final_Version_Managing_Safe_Caseloads.pdf (accessed 13 September 2017) Kane K. Capturing district nursing through a knowledge based electronic analysis tool (eCAT). Br J Community Nurs. 2014;19(3):116–24 Kilmann RH, Thomas KW. Developing a forced choice measure of conflict handling behaviour: The Mode instrument. Educat Psychologic Measure. 1977;37(2):309–25 Marquis BL, Huston CJ. Leadership roles and management functions in nursing.
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