District nurses (DNs) have an important role in person-centred practice within the community due to their involvement in assessing and caring for people principally in domiciliary settings, helping people live with long-term conditions and frailty, preventing deterioration and promoting health and wellbeing (Dickson et al, 2017). In the UK, DNs lead teams of community nurses who work within larger integrated teams. Similar roles exist in other countries (e.g. Australia, the Netherlands and Sweden), but most of these countries do not require a post-registration qualification. Despite the number of UK universities offering the Specialist Practitioner Qualification (the UK professional qualification) increasing from 33 to 43 since 2012 (Queens Nursing Institute (QNI), 2021), in the past 10 years, the numbers of qualified DNs has decreased by 43% in England (NHS, 2018; Royal College of Nursing and QNI, 2019) (data is unavailable in the other three UK countries). Anecdotally, there are increasing numbers of DNs leaving the discipline for other community roles, for example, advanced practitioners. This appears to be as a result of such roles being awarded a higher pay grade. However, there may be other contributory factors. The author's doctoral work revealed that DNs felt a ‘burden’ of responsibility for managing caseloads, teams and associated tasks, resulting in compromise to their wellbeing (Dickson et al, 2018; 2020). Maybin et al (2016) conducted a study for the Kings Fund which concurs. Their study sought to explore ‘good care’ from the perspectives of sservice users and district nursing staff; they found pressures of work, lack of resources, control and weak leadership as ‘getting in the way of good care’. They further suggest that it is contributing to reducing numbers of DNs. Another contributing factor may be the little attention being paid towards retention of nursing staff, as stated in a report by Buchan et al (2019). This workforce crisis is set within the backdrop of 40 000 vacancies in nursing across the UK, and the COVID-19 pandemic amplifying the problem (House of Commons Public Accounts Committee, 2020). Maybin et al (2016) suggest this decrease in the workforce has resulted in many community nursing teams becoming ‘task focused’, resulting in a negative impact on staff wellbeing and care outcomes. The perceived lack of visibility in district nursing, which is another factor (Goodman 1996; QNI, 2019; Dickson et al, 2020a), may be due to the little attention being given to the role/work of specialist practitionersin the literature. Most of the literature refers to DNs in general ‘community nursing’ terms, equating this role to a range of other roles being undertaken in communities. In the literature, the tasks performed by nurses ‘doing community nursing’, are given more privilege than the uniqueness of ‘being’ a DN. Therefore, it is challenging for DNs to build a body of knowledge that articulates their specialism.
The incongruity in the district nursing role
The author's doctoral work revealed two aspects of the DN role: the clinical expertise and the leadership/management aspects, impacting the ability to be person-centred (Dickson et al, 2018; 2020). The study, exploring the meaning of specialisation from the perspectives of DNs, concurs with the assertion that person-centredness is difficult to achieve (Manley et al, 2011; Clissett et al, 2013). The findings reveal a conceptual framework of DNs juggling the two distinct aspects of their role: clinical expertise and leadership/management, with an overarching theme of ‘burden of responsibility’. For the care-management aspects of their role, the DNs described their expertise as relational, anticipatory and enabling. This description aligns with several models that are advocated in policies by, for example, Integrated People-centred Healthcare (World Health Organization, 2015; Scottish Government, 2017b) and the House of Care (Coulter et al, 2013), as well as theories borrowed from other disciplines, such as behaviour change from psychology, salutogenisis from sociology and health promotion from the field of public health (Antanovski, 1996). District Nurses also draw from models of medical consultation, prescribing and clinical decision-making (Queens Nursing Institute Scotland (QNIS), 2015). However, absent from this data is the underpinning philosophy or theory that can help DNs make decisions when faced with people with complex health care needs in the context of increasing caseloads (Buchan, 2019).
This patchwork of theory that DNs draw from when considering their role and function, rather than a body of specialist DN knowledge, has not promoted DN identity, nor leadership development (Maybin et al. 2016). In addition, despite DNs in the study espousing transformational leadership, the described directive approach to leadership seems at odds with being relational, anticipatory and enabling, as demonstrated in care management (Dickson et al, 2018; 2020). Participants in the author's doctoral study also shared their experiences of high stress levels, which they felt was a result of holding leadership positions, a lack of practice developments and the resultant need to direct teams. This all appears incongruent with the person-centred care management they espoused. The need to adopt directive leadership approaches as a way of coping is perhaps unsurprising, but there can be a negative impact on individuals within teams if this is adopted and sustained over long periods of time (Li et al, 2018). Integrating the ‘doing’ with the ‘being’ in DN practice may help DNs consider their approach to practice and help reduce the sense of ‘burden’. The Person-centred Practice Framework (PCPF) (McCormack and McCance, 2017) is a means of striving beyond coping to a sense of coherence or healthfulness. It may offer a broader lens for DNs to adopt within the changing political landscape, which is moving towards humanising healthcare (Phelan et al, 2020) and giving voice to their specialism.
The current DN role is under professional scrutiny as the Nursing and Midwifery Council (NMC) debates whether the role continues to be a specialism — unique in its own right. To date, specialist education and practice has relied on outdated standards, but these are currently being reviewed. The foundation of the old standards were that DNs ‘exercise a higher level of judgement and decision-making’ (NMC, 2001), but the new draft standards suggest this statement reflects advanced practice rather than specialist practice. Specialist practice is defined in the new draft standards:
‘surpasses pre-registration nursing proficiencies in terms of areas such as assessment, diagnosis, decision making, care planning, coordination of care and care delivery specific to a particular person, context, setting or client group.’
The oversimplified, technical focus of this definition contributes to the reputation DNs have for advancing their own technical expertise, enabling them to practice autonomously within the home care setting. However, it does less to clarify whether they are specialist or advanced practitioners. Arguably, the four nursing meta-paradigms (person, environment, health and nursing) are visible in the draft standards, but the emphasis remains on ‘doing’ and less on how to ‘be’ a DN within either set of standards. However, competence takes centre stage in the draft standards. There is a welcome shift to ‘person-centred care’, for example, working with people's beliefs and values, promoting choice, shared decision-making, co-designing plans of care, strengths-based approaches and asset building. This renewed emphasis on working in partnership with patients and families has the potential for DNs to practice in person-centred ways and is echoed in the voluntary standards developed by the QNI Scotland (2015). The author suggests the missing links in the standards are those that promote this same approach to working in teams, creating flourishing work environments and those focused on how ‘to be a DN’. McCormack and McCance (2017; 2021) and others take a broader view of person-centred practice, viewing person-centred care as part of person-centred practice. They emphasise that being person-centred should be extended to every relationship and that micro- and macro-cultures need to create conditions for person-centredness. This is less reflected in the standards relating to leadership, and inclusion would be welcome. Rather than lists of leadership tasks focusing solely on risk-management and safety, which of course are crucial, consideration could be given to knowing the self as a leader and facilitative practice. Co-producing strategies and plans is the only indication in the standards that anything other than top-down leadership approach is advocated. To avoid an identity crisis in DNs, standards relating to knowing own beliefs and values are important. Our personhood, that is, our uniqueness as a person, connects us with others on a human level (McCormack and McCance, 2017). It encourages authentic engagement with patients, carers, families and colleagues and it encourages respectful relationships and guides decision-making (McCormack and Titchen, 2006; Manley, 2017). If management is about doing the right thing, and leadership about doing things right (Drucker 2010), DNs will struggle to know what the right thing is if they cannot understand their own personhood. Accepting responsibility takes courage, but sharing responsibility reduces levels of workload-induced stress and would help DNs draw on their relationship-based, anticipatory and enabling expertise they demonstrate in their interactions with patients and families (Dickson et al, 2020a). The link between sharing leadership and wellbeing has only been too evident in recent accounts of leadership during the current pandemic (Holge-Hazelton, 2021; Rosser et al, 2020).
A guiding framework to promote congruence in DN practice
Nielsen and Riiskjær (2013) suggest that a lack of theory means behaviours and interventions are most likely to emerge from learned behaviour. If the behaviours that are learned in practice are not consistent with person-centredness, then the leaders' behaviour is perpetuated. Rather than perpetuating a culture of workplace stress, problematic recruitment and retention of the workforce, the author contends the PCPF offers a theoretical framework that can help. The author believes this unifying framework has the potential to promote congruence and role identity, which will help DNs partake in unique ways of ‘being’, and will offer a means of applying other borrowed theories in practice. The domains of the PCPF are macro context, practice environment, pre-requisites and care processes, and the intended outcome is a healthful culture (McCormack and McCance, 2017; 2021). By understanding the macro context, DNs will be able to lead feeling confident and knowledgeable about ever-changing strategic priorities and respond to individual health needs. Being able to recognise and critique how policy is influencing their sphere of practice is a pre-requisite for being anticipatory and enabling in team and care management spaces.
Although creating a person-centred workplace culture is not privileged in policy nor standards, there is much to learn from a growing body of evidence that recognises the impact of the practice environment on practitioner wellbeing, as well as patient outcomes (Lynch et al, 2017; Cardiff et al, 2018; 2020; West et al, 2020). Lynch et al (2017) and Cardiff et al (2018) have used philosophical ideas of person-centredness and the PCPF to highlight the importance of relational leadership, while recognising the impact of culture and context, working in partnership and being other-centred and caring. Being relational and values-based is evident in the terminology of leader and associate, reflecting power-sharing and consideration for the associate's wellbeing and stage of development. It moves beyond hierarchical, directive approaches or with a sole focus on task, and the author suggests that it would help DNs share responsibility. In 2020, Cardiff et al (2020) developed earlier work (Manley et al, 2011) to identify guiding lights for effective workplace cultures. Collective leadership is one, as are living shared values, safe, critical (in terms of critique), creative learning environments, and change for the good which makes a difference. These guiding lights emerged from multiple stakeholders in a three-phase realist evaluation, incorporating a practice development approach. They suggest that using these guiding lights will help develop practice environments that result in flourishing people and places, effective working partnerships and practice development that makes a difference. The origins of this work, like the PCPF, are situated in critical theory. Critical theory holds that to know self, our values, beliefs and behaviours, we must go through a process of enlightenment, empowerment and emancipation (Fay, 1987). Mentorship relationships that help practitioners and leaders go through this process are a feature of learning environments. The author contends the full potential for the workplace as a learning environment is much overlooked. Rather, support for staff development is sought outside the workplace. Having a leader, mentor or critical friend (Hardiman and Dewing, 2014) who use facilitative practices to raise our consciousness about how we think and how we act, is crucial in finding new ways of being and acting.
Promoting congruence between education and district nursing practice
Promoting congruence between education and practice is a feature of current work being undertaken by the Person-centred Practice International Community of Practice (PCP ICOP) (McCormack, 2020; Dickson et al, 2020b; Phelan et al, 2020). The aim of this Erasmus Plus project is to develop a curriculum framework that develops person-centred healthcare practitioners. A consistent message in the literature (e.g. McCance et al, 2013; Nielsen and Riiskjær, 2013; McCormack and McCance, 2017) is that, if practitioners do not experience person-centredness, they will be unlikely person-centered practitioners. It is on this premise that the curriculum framework has been developed. The theoretical framework for this work included Woulter Hart's Purpose, Lifeworld and Systemsworld model (2019) as well as the PCPF. These two models emphasise the importance of creating conditions for person-centredness, which will be evident in proposed learning environments as well as teaching, learning and assessment strategies. Hart warns against the over bureaucratisation of organisations (and, therefore, curricula). He suggests that standards can constrain the quality of interactions between people in the lifeworld domain by key performance indicators, policies, procedures and other rules in the systemsworld domain, aimed at standardising practice. Ultimately, this can affect the overall purpose of the organisation or programme.
The development of philosophical and pedagogical principles in this Erasmus Plus project drew on multiple datasets from five European countries. In a critical hermeneutic praxis, the teams used multiple rounds of data analysis and dialogue to move from ‘the parts to the whole’ in a hermeneutic circle until there was what Gadamer refers to as ‘fusion of horizons’ (Dickson et al, 2020b). This distillation of data revealed four philosophical principles reflecting the theoretical framework. In addition, the curriculum is based on constructivism to develop person-centred healthcare practitioners, the principles reflecting humanistic learning theories. These principles focus on self-understanding, self-developmentand self-transformation (. Illeris, 2014; Freire, 1996), thus the overarching principle is a curriculum that is transformative, uniting ‘doing’ with ‘being’. Learning to be transformative as suggested by Illeris (2014), curricula must address the cognitive and the emotional, as well as the social dimensions of mental capacity and learning, which is reflected in the second principle, relational or connected with the self. The intention of this principle is to emphasise enabling understanding of the self and how we relate with others. Connecting with others and the context will develop an awareness in how learners behave in different situations. It also enables them to be reflexive and recognise and challenge attitudes, rituals, routines and other structures which are taken for granted. Using this principle helps prepare them to be bold and to question and equips them to grasp opportunities for change. The third principle, co-construction, reflects democratisation of the curriculum, reflective of the changes seen in practice, aligned with humanising healthcare practices driven by current global healthcare strategy and professional requirements. The fourth principle is pragmatism. Healthcare disciplines are in the main practical disciplines, with learning taking place in the ‘real world of practice’. Competence development is central to any healthcare professional programme requirement, but encountering learning situations are rarely ‘textbook’. They need to develop expertise in integrating theory and practice seamlessly in diverse complex situations. They will also need the confidence to challenge organisational and social structures and harness social change.
The author contends that experiencing person-centredness while learning to be a DN on the post-registration programme will give DN educators in practice and university the opportunity to be positive role models. Using this philosophical and theoretical lens, there is potential to develop person-centred DNs who are advancing practice, developing effective workplace cultures and advocating for their profession (Dickson et al, 2020a). The PCPF gives a structure for learning, while enabling DNs to integrate the multitude of theories borrowed from other disciplines, and apply them to different, often challenging, situations in practice. Titchen (2000) refers to this as professional artistry. Concurring with other researchers in this field, her work identifies ‘having a particular way of being and becoming’ as a key aspect of a professional demonstrating artistry. Her later work in 2019 (Tichten, 2019) revealed knowledge gained through praxis of one's own ontology (personhood) and epistemology as informing expert practitioners' ways of being. The development of professional artistry offers direction to the DNs seeking to articulate their specialism. The emphasis on ‘whole person’ learning and development promotes wellbeing, and may also go some way in addressing current workforce issues (VassbØ et al, 2019; McCormack, 2020).
The PCPF offers a framework to help DNs create their own theoretical knowledge base, which can help them be an advocate for themselves and their patients in full knowledge of their expertise. The current over-reliance solely on policy, professional standards and borrowed theory is not enough to develop DNs who can articulate their specialist knowledge in the community. Preparation through a person-centred curriculum and applying the PCPF are the missing links in developing contemporary DN practice. Having developed professional artistry as person-centred DNs, I proffer DNs will value their own, and be valued for their personhood and specialism and be able to put down their juggling balls and be the conductor of the orchestra (Dickson, 2020). Recognising decisions made by themselves and others that are systems-led rather than person-led (Hart, 2019) would mean actions being undertaken respect the personhood of care receivers, as well as caregivers. Understanding their own personhood is the first step in setting the direction of the continued development of their profession. Using the PCPF and integrating their practitioner/leader role by living person-centred values, will help DNs be courageous in their move with the advanced practice sphere, rather than looking for alternative career choices. It will enable them to ‘dig deep’ into what Sharmer refers to as ‘life is calling them to do’ - helping them to systematically consider what their purpose is, and how they may best serve the needs of their community, and through that, develop a new identity of service and purpose. Using the PCPF to develop flourishing workplaces will create workplaces where people want to work, and there is less stress and burnout for themselves and their teams.
- It is challenging for district nurses to build a body of knowledge that articulates their specialism
- Integrating the ‘doing’ with the ‘being’ of district nurses (DN) practice may help DNs to consider their approach to practice and help reduce the sense of ‘burden’ they feel
- The Person-centred Practice Framework can help DNs create their own theoretical knowledge-base, which can help them be an advocate for themselves and their patients, while having full knowledge of their areas of expertise
- Understanding personhood is key to avoiding the current identity crisis in district nursing
- To promote person-centred district nursing, there must be congruence between education and practice
CPD reflective questions
- What do you do that advocates for service-users, yourself, your team and district nursing?
- In what ways does knowledge of your own personhood help you to make complex decisions in practice?
- How can the Person-centred Practice Framework help you integrate district nursing knowledge and practice?