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Are we ready for one-size-fits-all?

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Do community nursing roles need to change? Do community nursing roles need to change?

Practice nurse, advanced nurse practitioner, nurse practitioner, district nurse, community matron, school nurse, public health nurse, community children's nurse, health visitor. These are just some of the job roles of nurses working in the community. And while each job title reflects a different purpose and a different set of skills in the NHS, are so many job titles required? And are job titles really that important to patients who just want good quality care?

This was the subject of one of the fringe sessions at RCN Congress last month. Members of the RCN's Practice Nurses' Association asked whether the NHS was ready for a one-size-fits-all community nurse.

The origins of the session stemmed from the release of key policy documents such as the Five Year Forward View and the Shape of Caring Review that floated the idea of crossover in the roles of different community nurses. More generic pre-registration training for nurses, to give them a general nursing greater baseline knowledge, was suggested. The Five Year Forward View in particular referred to a future workforce that is fit for purpose to be able to deal with the ageing population and their plethora of comorbidities.

Practice nurses and district nurses were recognised as having a vital role to play in this, but there was acceptance that the roles as they are today might not be best suited to handle these changes.
The Five Year Forward View also proposed new models of primary care such as multispecialty community providers, primary and acute care systems, and emergency care networks. There are currently 29 vanguard sites, piloting these models to evaluate them for sustainability. GP practice federations and super practices are becoming more commonplace. It was argued in the fringe session that nursing roles must also adapt to fit both within these new organisations and the NHS as a whole.

'Practice nurses and district nurses certainly have roles that complement each other and there could be crossover between the roles. The role of the nurse working in those organisations might be quite different in the future,' says Karen Storey, primary care lead nurse for workforce at Health Education West Midlands. 'It was agreed by the Practice Nurses' Association that it was a timely opportunity, given the release of policy documents, to start talking about the role and possible new roles that may emerge. There is an opportunity for all the roles to be renewed and revisited, to work in different ways and to be responsive to patients' needs.'

However, some believe that that nurses working in the community are already too specialised to be able to cover such a wide range of conditions and comorbidities.

Marie Therese Massey, chair of the Practice Nurses' Association at the RCN and a senior lecturer in adult nursing at Sheffield Hallam University, thinks that it could be difficult to completely overhaul the role of the community nurse because of strong professional identities.

Kirsty Armstrong, senior lecturer in primary care at London's Kingston University and a practice nurse, believes that a one-size-fits-all nurse is simply not possible. 'Practice nurses and district nurses have very different specialisms that are just too complex to be carried out by each other. I don't see how a district nurse could conduct travel health or child immunisations or cervical screening as these are really specialised, or how a practice nurse could carry out complex compression bandaging.'

In the beginning
When considering how to implement and train a one-size- fits-all community nurse the first thing to look at would be the initial university training of nurses.

Debbie Brown, a specialist practitioner in practice nursing from South London, believes that nurses should be 'generalist specialists, or specialist generalists' and that titles should not matter. 'I think that nurse training in the first couple of years should be a generalised pathway that will ensure nurses have the skills that will equip them to see patients holistically,' she says.

'Nurses need to be able to treat the patient as a whole and take into account everything about the patient, having a proactive approach to wellbeing and self care.

'We need to be looking at training. Whether it's practice nurses, district nurses, community matrons or hospital- based nurses it's about having generalised training across all disciplines to look at how we can ensure that our nurses of the future have got the skills to see patients with comorbidities.'
This was mentioned in the Shape of Caring Review carried out by Lord Willis in 2014/15. The review put forward the recommendation that all student nurses should undertake two years of general nursing training and then move into a specialism in the third year. Lord Willis told Independent Nurse that this would ensure that all nurses have a standard set of skills applicable to any setting before they complete a year focused on their chosen specialism.

However, that has already led some nurses to claim that had generalised training been compulsory, they may not have made it through their nurse training to become a specialist.

The second point, and one that appears to be more divisive, is whether the role of a nurse working in the community or in practice needs to cover more conditions and settings. This could mean that nurses working in the community have greater flexibility to either work in practice or do home visits, or have a broader clinical knowledge with the competencies to be able to handle the majority of conditions that present in the community. Ms Massey says that she recognises the need for nurses to become more flexible and that 'we can't keep working in our silos.'

Ms Brown believes that there could be a team of nurses who are all generalists working in the community that are able to deal with a number of different scenarios. 'I'm not saying that this is the right way, but we've got to look at different options. What we are doing right now is not working,' she says.

Ms Brown attributes part of this to there not being enough nurses in the community in general, but emphasises that 'while waiting for recruitment of nurses to catch up with demand we can be looking at what we can do with the current set of staff.'

What would a one-size-fits-all community nurse look like? This is a more difficult question to answer.
'You would have to have a nurse that could deliver care in people's homes, be highly specialised, be autonomous, a critical thinker and could move seamlessly from one environment to the next. That's what I would say, but I don't know whether that's a realistic role,' says Ms Massey.

However, Ms Brown believes that it isn't about having a 'super nurse' who does everything. 'It's about having a role that complements other existing roles.'

Ms Armstrong, however, doesn't believe that this flexibility would fix the wider problems in community nursing. 'What you will have is a very superficial approach to a lot of very complex issues. District nurses are fantastic at some things and not so good at others. Practice nurses can't do everything district nurses do. For example, when a district nurse has to administer a syringe driver. That's very time intensive training and practice. I don't think you could mix practice hours with the hours required for this. You're talking about very different roles. Just because nurse is in the job title doesn't mean they can do the same thing.'

Professional identity
Caroline Dickson, chair of the RCN District Nurse Forum, says that they tried for district nurses and public health nurses to operate as community health nurses in Edinburgh, but it wasn't as successful as they had hoped. 'Many of them held on to their professional identities quite fiercely. It is very difficult for some nurses to move away from their professional identities. However, the change came from the top, there was little ownership from the nurses themselves,' she says.

If the nurses were to drive this change themselves it might be more widely accepted. This loyalty to job titles may stem from district nurses having to complete a Specialist Practitioner Qualification (SPQ), to gain the district nurse job title.

Another thing raised at the debate was the public perception of nurses and how this relates to job roles and titles. Ms Massey says that if a patient sees a nurse in their home, they will call them a district nurse, a nurse in a practice will be a practice nurse and a nurse situated in a school will be called a school nurse. 'Have we asked the public if they would be OK with a new type of nurse? We don't know the answer to that, but it could be worth finding out how the public would react to this,' she adds.

In relation to this Ms Massey, in her role as a lecturer, says that students very rarely come and talk to her about becoming a hybrid nurse. 'They ask me how they can become practice nurses, or district nurses or health visitors. At the moment they are also only seeing the clearly defined roles. If we are going to encourage students to go into the community we need to help them see what they might look like in five years' time.'

A further question raised at the fringe session debate was around nurses who had chosen a specialist branch of nursing, such as school nurses. 'How can we maintain specialism in niche areas with a generic role?' asked one attendee of the session.

The difficulty is in the definition. Some agreed that the community nursing role needs to evolve and adapt to remain sustainable and support the NHS. Exactly, what it needs to adapt to is less clear. Others believe that the roles are just too complex for joint training and working. One thing agreed on is that continuing to work as we have done up until now is not the solution.

1. Health Education England. Raising the bar. Shape of caring: A review of the future education and training of registered nurses and care assistants.
2. NHS England. Five year forward view. 2015.
3. Study of the implementation of a new community health nurse role in scotland. 2012.

What do you think? Leave a comment below or tweet your views to @IndyNurseMag

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@Jill Gould. You don't appear to have much idea what a Practice Nurse does. Did you know that most Practice Nurses work independently, all are accountable for their actions, a major part of the role of those working in less affluent areas is to address the health inequalities of their population and that we do this whilst ticking endless boxes so that the Practice we work for earns enough to keep us in employment. Many practice nurses do home visits and we see plenty of patients who require compression bandages for both the elderly and those with long term substance misuse
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Interesting article but highly biased, as usual, towards the view of Practice Nurses, making it appear that the roles are comparable. However, the fundamental core principles are very different, in that as a District Nurse, an important part of the role is in addressing health inequalities, providing services to the most vulnerable, safeguarding adults who receive care from all types of agencies behind closed doors, quality assurance of the care received within multiple venues (including residential homes), and providing care at the palliative and end-of-life stages. While this article alludes to silos, it misses the point that District Nurses have accountability for the care of a defined population that extends far beyond the cost-driven, target-minded, GP-influenced tasks, as there is still a degree of autonomy in assessing and prioritising health needs. District Nurses retain a professional accountability for the care provided by their teams (and others) to a defined population, and although the move is towards making their services more target-driven, this would be at a great loss to this client group and the wider quality of life issues that are quietly addressed in the background, not easily captured by data and statistics. While Practice Nurses certainly have a public health role, their practice is inevitably more task driven and not really comparable to the managerial, leadership, educational, quality assurance and complex generalist-practice roles the Qualified District Nurse undertakes to ensure these most vulnerable of patients are safely cared for. This article only alludes to tasks- which in itself informs the reader that there was little input from the District Nursing perspective.
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