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RCN's primary care lynchpin

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Dr Marina Lupari is the RCN's new professional lead for primary and community care. In an exclusive interview, she tells Rita Som what drives her, what needs to be done and why she is best placed to do it

Rita: What will your role encompass?

Marina: I will have the professional lead responsibility for primary and community care, so all nurses working in the primary care setting. I won't have responsibility for school or prison nurses. For me, I use a simple definition for primary care that means everything outside of the hospital setting. I like to use that definition, as opposed to primary and community settings, so people are able to get a sense that we are all nurses working together, not apart.

R: How will you cater for the different groups of primary care and community nurses?

M: In my role as professional lead, it is important to look at the big issues that nurses deal with on a day-to-day basis. The issues tend to fall into similar themes so it is about how do they develop in their roles, what does their education framework look like, how do they maintain their professionalism, how do they maintain their identity within the nursing family. Driving the focus for the future then is how do primary care nurses achieve the policy directives that relate specifically to them? Even though the different groups appear diverse, they are all nurses at the heart of it all and with this comes a shared set of common themes and challenges.

R: What are those common themes and challenges?

M: The biggest challenge for us in the primary care world is the acknowledgement of the role that we have, and the importance that we have in the whole system delivery of care. My remit will be across the four countries and they share the same challenges. The big challenges are the older population, the pressures of people with long-term conditions, and the financial situation. We don't have enough money to do everything we could do as a health service. Whenever you look at these challenges, and you look at our policy and strategic direction in the health service across the four countries, primary care can be the solution. The only way that the health service can achieve is to keep people at home. The primary care nurses will make this possible. So that's the biggest issue. Once people understand the importance of the nurses working in this sector, that's where we will get results [for patients and ourselves].

Another issue common to the groups of nurses within primary care is the gap between primary care and hospital nurses. We need to streamline that gap. For a person who is receiving care in a GP practice from a Practice Nurse or District Nurse when they move to hospital, then information should follow them, nurses in the hospital setting should be working with primary care nurse colleagues to agree what is added for them to return as quickly as possible to their own homes. That is a big issue for all the nurses, because nurses in the community don't understand the role of the hospital nurse, the hospital nurse doesn't understand the role of the community nurse and god love the patient in the middle of it all.

The solution is to take this opportunity to bring primary care to the forefront and get the acknowledgement that we are the solution. But equally it's about reducing that gap between acute and primary care. To achieve that would be amazing.

R: How do you think you could achieve that?

M: The first thing is that I'm not on my own I this. In the RCN, there are very well established forums that have been working tirelessly on this in their own time – the District Nursing and the Practice Nurse forums. I'm only a new person in a role, which has a history, within an organisation that is on top of the challenges. I'm starting with a lot of very informed, very enthusiastic people. For me, the first thing is to harness that energy. There are members champing at the bit to do something and this year at RCN Congress a motion was passed to ask Council to lobby commissioners and regulators to support the development of a recognised national qualification and career pathway for practice nursing. In the next couple of months the key people will be called together so they can inform me and we will begin to develop the work plan. My period of secondment is for three years so, we need to agree the priorities and decided what is it that we are going to achieve in those three years.

We have lots of nurses who are very passionate and informed, and then we have other nurses who are very busy in the day-to-day work. Maybe because they are based within a local authority, they don't have access to the information that is ongoing. So we need to do

something to inform nurses, because they will be the ones who become the champions and the voices within primary care. So for me, this is where I would like to target efforts for the foreseeable future. To get these nurses to feel inspired and informed. It is about the culture out there. They have to take ownership of this. At the end of the day, I'm one person in a defined role. The RCN is an organisation who responds to our members' requests, so we have to empower them. I need them to breathe, eat and sleep as primary care nurses. They need to influence their colleagues. It won't be possible to achieve sustainable change unless we do that. Culture change is the hardest thing for any organisation to do.

R: If you could ask these nurses now to do one thing to change the culture, what would it be?

M: Be proud. Be proud of your role in the community and be proud of your role as a nurse in the health service. Community nursing is seen as the poor relation of hospital nursing. They are often seen as the less qualified nurses; to go and do meaningful work in a person's own home, spend time working with a carer, that's seen as not being a nurse. To work with a carer to support someone to stay at home has much more of an impact on that person and their overall health. That's the clear message I want to convey. We have district nurses doing fantastic things, working with stroke survivors, rehabilitating and keeping people at home. But there is little acknowledgement of this work.

The UK and NI are leading the way [in terms of community nursing in] Europe. We should be proud of our nursing structure. No other European country has it. We work with two consortiums, one in Athens and Lithuania and another in Malta, and they came over to see what an integrated system looked like and what nursing in a community setting looks like. In Malta their health system is focused on the acute setting and had no community nurses. Malta has just created an outreach into the community based on the model of care we have in the UK – a fantastic achievement. These countries are following us – we are the leaders.

The UK has a problem in that as a health service we don't acknowledge primary care. We actually do it very well, even if we know there is so much more we could be doing. This was my main reason for coming to this post. What we are lacking is the passion and enthusiasm to be the champions of nursing in the community.

R: What experience do you bring to the role?

M: I came into nursing as mature student, as a married person in the late 80s when we were just getting to the stage that married people would be accepted into nursing. I'm described as being unique and different and I hope that is a good thing. I ended up after two and a half years in a hospital going out into the community. Most of my career has been spent in a community setting across a range of posts. I have had fantastic opportunities to work within the University of Ulster Community Nursing student programme where I was option leader for health visiting and worked alongside mental health, practice nursing, occupational health and of course district nursing colleagues. That gave me the sense of being part of a community nursing team and enabled me to flourish. I worked with all disciplines of nurses to role out nurse prescribing in Northern Ireland. That gave me an opportunity to work as a community service manager. My biggest achievement was a redesign of community nursing for the community trust. I introduced a new way of working for the older person with comorbidities. Whole new role, whole new education. That was in 2004. In 2007, the research into the redesign demonstrated that the new role was cost effective and by working in the community setting we had been able to reduce hospitalisations. My experience has been all about improvement and how to work and change. The person taking on this role needed to bring an evidence-based approach, and an understanding of primary care and it needed to be someone who had proved they knew how to design services and, above all, work with people. That's how I got to the point where I put myself forward.

R: What did this service redesign look like?

M: That redesign won me a Frontline First award from the RCN. That was fabulous for me, coming from Northern Ireland. The award brought me a lot of recognition. I was able then to see how in a short period of time something can be taken, communicated and built on (it was that piece of work led to the work with Malta, Athens and Lithuania). Since then I've had the opportunity to work with different champions across England and Scotland.

The redesign: I listened to service users who told me they didn't care about nursing titles, they didn't understand the different roles. The other key message was that they didn't want loved ones to go to hospital. I heard it time and time again. Then I looked at why people went into hospital and realised that often people knew they were becoming unwell but there was nothing to help them manage their illness at home. The model of holistic nursing was reactionary, in that if you were ill we'd treat you. But there was nobody for people with a chronic condition, who knew they were getting worse before they reached that point. So we set up a service to identify people who were 'revolving door' patients. We did a major redesign, including education, and 16 nurses went into the new role and started working with patients. Over time the patients stopped relying on the nurse and self-management groups evolved with patients able to support others. That's a big passion of mine, giving a person ownership of themselves rather than the health service coming into the rescue.

R: Why this RCN role now?

M: It is all a fantastic opportunity. I'll work as part of a team within the RCN: Amanda Cheesley, lead for long-term conditions, Rachel Thompson, lead for dementia, Dawn Garrett, lead for older people and Helen Donovan, public health lead. This experienced RCN team will be working with me to help me achieve my aims for primary and community care nurses. I see myself as a lynch pin, to pull people together, to be the voice of all the primary and community care nursing. IN

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